Wiki HPI and MDM Level challenge

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fredcpc

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Would you mind looking at another one for me, it is kinda different as are many of these I am posting.
CC: DM, HTN, and Hypothyroidism.
HPI: He complains of left hip pain with activity such as walking or shoveling. He thinks ED started at the same time of his hip surgery. He has a normal libido. He is interested in meds for ED. He thinks that fasting blood glucoses are ranging about 170 to 150. Denies polyuria or polydipsia. What is the HPI level on this one?
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And, the MDM: 1) DM. Suspect control will be poor. Need f/u glycohemoglobin and urine micro alubumin. He may need to add sulfourea to regimen to achieve glycemic control. 2) HTN. Control is good. Will continue same antihypertensive regimen. Need clarification on atenolol usage.
3) Actinic Keratosis. With pts consent, 6 keratoses were destroyed using liquid nitrogen dual freeze technique.
4) Dyslipidemia. Needs F/u lipid panel to monitor gemfibrozil use.
:cool:
I alread know the CPT code for the Karatosis. I am just looking for the MDM level. Thoughts? Feedback??
 
CC: DM, HTN, and Hypothyroidism.

HPI: He complains of left hip pain-LOCATION
with activity such as walking or shoveling-CONTEXT
He thinks ED started at the same time of his hip surgery-TIMING
He has a normal libido. He is interested in meds for ED. He thinks that fasting blood glucoses are ranging about 170 to 150.-SEVERITY
Denies polyuria or polydipsia.-ROS-GU

I got an extensive level for HPI. I did it 2 ways. First: The note discussing the status of 3 chronic illnesses-this would give you the extensive under 1997. Second: I used the elements from 1995 to see what I could come up with. I capitalize above. The elements can be pulled from several different issues, not just one.


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And, the MDM: 1) DM. Suspect control will be poor. ESTABLISHED PROBLEM, NOT RESOLVING-2 POINTS
Need f/u glycohemoglobin and urine micro alubumin-LAB-ADDITIONAL WORK UP-1 POINT. He may need to add sulfourea to regimen to achieve glycemic control. 2) HTN. Control is good.-ESTABLISHED PROBLEM-CONTROLLED-1 POINT Will continue same antihypertensive regimen-RX DRUG MANAGEMENT. Need clarification on atenolol usage.
3) Actinic Keratosis. With pts consent, 6 keratoses were destroyed using liquid nitrogen dual freeze technique.-COULD BE A NEW PROBLEM OR AN EST, NOT HEALING AS EXPECTED-EITHER 3 OR 2 POINTS
4) Dyslipidemia. Needs F/u lipid panel to monitor gemfibrozil use.-ESTABLISHED PROBLEM 1 POINT

DX OPTIONS: 5-6 POINTS
DATA: 1 POINT
RISK: MODERATE

COULD BE A MODERATE RISK MDM.

I hope all of this helps.

Suzan

I alread know the CPT code for the Karatosis. I am just looking for the MDM level. Thoughts? Feedback??
 
HpI and MDM Level Challenge

Aloha Suzan -- thank you. Quality counting on both parts. I appreciate your 1995 and 1997 perspectives. But on the HPI, when you say extensive do you mean detailed? :D
 
She meant extensive - 4+ HPI elements = extensive (1995) - it's either brief, or extensive...

Extensive is required for Detailed and Comp. overall history, though, if that's what you meant.;)
 
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