I have a Doctor's Impression statement that reads, "Anorexia and Gastropareis." And Gastroparesis can be a cause of Anorexia. So is the "and" enough to Code First the Anorexia then the Gastropareis? Or, do we code them completely separate?
The probability, suspecious sort of diagnosis still do not rule out the opposite conditions-here it still do not rule out the cardiac pain too; And all the more when there is a strong sibling history of MI and the medical necessity to prescribe Nitro by the doctor- means he wants to rule out unstable angina, angina pectoris still ; if the pain still not relieved with nitro, doctor cannot rule out cardiac like MIYou are right about the non-cardiac pain statement. But the statement was "suspect this is non-cardiac pain, probably chest wall." The dr. recommended Darvocet, which is a risky pain reliever. However, he also Rx'd Nitroglycerin. He also did an EKG.
Also, the patient also had a brother that died of an MI. You may be right here, but why the Nitro?
I think that the doctor should have listed hip pain in his Impression statement, since it was part of the chief complaint; the same can be said about erectile dysfunction. That would have made their significance to this visit more obvious.Thank you for the workup. Nice. The ROS is Comp; and the PFSH is also Comp. So we have a detailed History.
The DM and HTN are actually on follow up, but it may not make a difference in the MDM. But this leads to my real question.
1) Which of the guidelines did you use to grade the HPI?
2) What is your take on HPI as it relates to chronic problems and the 1995 guidelines? I feel good about some of my codes, but this is a shady area.