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Wiki HPI for F/U visit for elevated BP

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dballard2004

dballard2004

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How many elements of HPI do you see here, please?

CC: Pt here for follow-up visit for recheck of blood pressure

Other: I was seen 2 weeks ago for a sore throat and my blood pressure was high. I was told that I should come back and have it checked. I feel fine.

HPI: Pt noted to have elevated blood pressure at previous visit.
 
Context and qualify

If I am interpreting your scenario correctly ... Since you can only count what the PROVIDER documented (not what the patient wrote) ...

Context (on previous visit)
Quality (elevated)


F Tessa Bartels, CPC, CEMC
 
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Thanks. I don't even know why the "other" part was in the note anyway. It is just a part of our EMR that allows patients to enter this kind of info when they check-in.
 
Another question.....this was a follow-up visit for elevated BP and the patient's BP was elevated on this visit as well and the provider recommended another follow-up visit. I assigned low risk here but one of my coders is questioning this. She feels that this should be minimal risk since no OTCs were given and no medications were prescribed. I think low is appropriate since the pressure is elevated and the provider wants the patient to follow-up. Would I be safe to assume that if a follow-up visit is recommended for something like this since the patient has already presented twice with the elevated BP, that low risk is correct? Thanks.
 
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Table of risk

Your risk is the "HIGHEST" level you get from the 9 boxes on the table.

So if you had an acute, uncomplicated illness (low risk) but prescribed a drug for treatment (moderate risk) you would have Moderate Risk.

Although I can't tell if patient has been diagnosed with HTN from the brief example, I would be willing to listen to arguments for Moderate Risk (one or more chronic illnesses with mild exacerbation / progression)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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