Wiki Help with determining History type

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renakirk

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If a patient is coming in to discuss lab results, has a new dx, such as hypothyroidism for which they are given a script for thyroid replacement. I've got: "here to follow-up lab results," VS were obtained, noted no allergies, date of LMP, and a note "well-nourished, well-developed, no apparent distress, afebrile, BMI out of recommended rnge, Class I obesity with BMI 32.1.

I have a review of 3 systems (constituitonal, endocine and allergy), also that pt does not smoke (social hx). What level hx would you call that?

Thanks in advance!:confused:
 
Because the patient is only coming in to discuss lab results, I would say that the hypothyroidism is a brief HPI. You have a detailed ROS and PFSH, but you can only use an expanded problem focused History due to the HPI elements. That is just my take on it. Hope that helps.

I would code a 99213 - exp prob foc HPI, Exam not needed, and a moderate MDM due to the New dx with work up and chronic illness with mild exacerbation.
 
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