Hpi

ARCPC9491

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Okay, I'm beating myself up today .... I'm tired and want to go home!!:)

Type 2 diabetes, for 10 years, currently on glimepiride 4 mg bid. Denies any retinopathy, neuropathy, or nephropathy. No history of foot problem. Patient checks her blood sugars 2 to 3 times a day.

Ok, so I've got duration, mod factor, associated signs and symptoms - can i use 'checks her blood sugars 2 to 3 times a day' for timing?
 

dmaec

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hmmm... I don't think I would. To me it's more of a modifying factor - checking it to determine what it is - to see if it's high/low - eat, don't eat ;)...

{that's my opinion on the posted matter}
 

sadamcik

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Lubbock, Texas
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I have to agree with dmaec. You only have 3 HPI no matter how hard you look at it. I have had this challenge daily for many yrs in a large physician multi specialty practice. Many drs do not realize how little they give the coder in documentation and then they wonder why the service they provided doesn't rate a higher level. :confused:

Sylvia, CCS-P, CPC, CPC-I
 

ARCPC9491

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I so agree Sylvia, I always get stuck with say a 99243 - because I am 1 HPI element off....only one more, and I could have a 99244. I stress, stress, stress that, how little documentation they actually need, but they give even less than little! LOL if that makes any sense.
 
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Albany, NY
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I question, do you really have modifying factor? It doesn't say the medication makes the diabetes better or worse. That would fall more under current medications which is not an HPI element.

Okay, I'm beating myself up today .... I'm tired and want to go home!!:)

Type 2 diabetes, for 10 years, currently on glimepiride 4 mg bid. Denies any retinopathy, neuropathy, or nephropathy. No history of foot problem. Patient checks her blood sugars 2 to 3 times a day.

Ok, so I've got duration, mod factor, associated signs and symptoms - can i use 'checks her blood sugars 2 to 3 times a day' for timing?
 
Messages
155
Location
Albany, NY
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Type II.

No. Type II doesn't support severity.

Severity is a rating or description of the symptom or pain (such as severe, mild, worse, or the 10 scale)
 
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