carriganm
Networker
I have a question on coding the 'Number and Complexity of Problems Addressed' More often than not patient comes in for a follow-up of their chronic conditions and in the assessment it states that patient is seeing improvement and to continue their rx or OTC. How do I code this? There are no data points to be counted and 2/3 categories need to be met. In my opinion 'improving' doesn't fit any of the definitions in the complexity area. Below is an example of a chart note I'm currently stuck on. Any help would be extremely appreciated. Thanks! .
1. Gastroesophageal reflux disease-
Patient noting improvement with use of DGL tablets. I advised him that we will need to do this for several months prior to trying to discontinue the pantoprazole so I recommended that he continue that but can use it on an as-needed basis as he did previously. We will see him back in 2 months and look at trying to wean the pantoprazole at that point.
K21.9: Gastro-esophageal reflux disease without esophagitis
2. Iron deficiency anemia-
Improvement in overall energy with current iron therapy and even noting improvement in sleep. We will continue his current iron therapy and recheck his iron studies in 2 months prior to his follow-up visit.
D50.9: Iron deficiency anemia, unspecified
1. Gastroesophageal reflux disease-
Patient noting improvement with use of DGL tablets. I advised him that we will need to do this for several months prior to trying to discontinue the pantoprazole so I recommended that he continue that but can use it on an as-needed basis as he did previously. We will see him back in 2 months and look at trying to wean the pantoprazole at that point.
K21.9: Gastro-esophageal reflux disease without esophagitis
2. Iron deficiency anemia-
Improvement in overall energy with current iron therapy and even noting improvement in sleep. We will continue his current iron therapy and recheck his iron studies in 2 months prior to his follow-up visit.
D50.9: Iron deficiency anemia, unspecified
