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Wiki Chief Complaint "H/O DM2"

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heatherwinters

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A new patient presented today to the clinic. The only documentation I have a chief complaint is "H/O DM2". Under HPI, I have a number of problems documented. Can I use this to code an E/M and draw from the HPI or do I have to code as a new patient preventative visit?
 
it depends....

What was the focus of the visit? Was the patient there to discuss their hx of DM and discuss on-going care? If so, you would choose an E/M code based on the level of hx, exam and decision making. If the patient was there for routine screenings and an overall check-up but without specific detailed discussion of diabetes, it is probably a preventive.
 
Heather,

Is there any documentation about what med pt is taking for the DM2. Did the dr address any of the "documented problems" or give a status of those problems.

Roxanne Thames, CPC



heatherwinters said:
A new patient presented today to the clinic. The only documentation I have a chief complaint is "H/O DM2". Under HPI, I have a number of problems documented. Can I use this to code an E/M and draw from the HPI or do I have to code as a new patient preventative visit?
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