karlam
Networker
Could someone please give me their opinion on what to count for HPI elements here? I have a lot of trouble with the chronic conditions (95 guidelines).
Chief complaint: Medication refill.
History of HTN and diabetes mellitus 2. Here for medication refill. Has no complaints at this time. Has fairly well controlled diabetes mellitus, on oral agent. Tolerating medication well. No adverse side effects. Monitors blood sugars 1-2 times per week with numbers ranging in 130s. Is diabetic, diet compliant. Denies hypoglycemic episodes. History of HTN, adequately controlled on current agent. Medications tolerated. Occasionally monitors BP at home. No chest pain or shortness of breath. No edema. ROS negative except as mentioned.
PMH: HTN, diabetes mellitus type 2.
I clearly get the timing - "1-2 times per week" and the severity - "in 130's". I'm looking for 2 more elements to justify the 99214. In general, how would you use, if at all, "tolerating meds" or "no side effects"? Any other pointers?
Thanks!!!
Chief complaint: Medication refill.
History of HTN and diabetes mellitus 2. Here for medication refill. Has no complaints at this time. Has fairly well controlled diabetes mellitus, on oral agent. Tolerating medication well. No adverse side effects. Monitors blood sugars 1-2 times per week with numbers ranging in 130s. Is diabetic, diet compliant. Denies hypoglycemic episodes. History of HTN, adequately controlled on current agent. Medications tolerated. Occasionally monitors BP at home. No chest pain or shortness of breath. No edema. ROS negative except as mentioned.
PMH: HTN, diabetes mellitus type 2.
I clearly get the timing - "1-2 times per week" and the severity - "in 130's". I'm looking for 2 more elements to justify the 99214. In general, how would you use, if at all, "tolerating meds" or "no side effects"? Any other pointers?
Thanks!!!