carriganm
Networker
Hello there!
I have a provider in our office that I struggle so much with her HPI's. She will list the labs drawn and the results next to them. Occasionally listing meds taken. Below is an example. I have been told that I can't count these as status of 3 conditions because it is out of the scope of the coder to determine which conditions these labs are associated with as well as determining whether they are stable, improving, ect. Which I totally agree with. Here is an example of one I am having a hard time with.
Pt. presents today in f/up on labs.
Discussed labs drawn on 7/5/17
CMP: Glu 108 otherwise wnl.
A1c: 5.6
Insulin: 17
TSH: 1.33 Takes levo 137 mcg and lio 10 mcg
fT4: 0.92
fT3: 2.6
Lipids: 112/119/57/31 Takes atorvastatin 40 mg.
CBC: wnl
Pt has seen a health coach a couple of times. Will set her back up with her.
Pt. is sxic (very fatigued) and fT4 is low, fT3 is low normal.
So she listed the date the labs are drawn, can this be counted as timing? (I don't think so, but another coder counts this in our office)
Also she lists two different meds which by the looks of it is for two completely different conditions. Do I get 2 points for this for modifying factors? Or just one?
Very fatigued. I am counting this as associated signs and symptoms.
Then she reiterates that the Ft4 and Ft3 are low and low normal. Can I count this as quality?
Thank you for any help you can give. I have tried giving her pointers to make her HPI's better but she doesn't seem to make an effort.
I have a provider in our office that I struggle so much with her HPI's. She will list the labs drawn and the results next to them. Occasionally listing meds taken. Below is an example. I have been told that I can't count these as status of 3 conditions because it is out of the scope of the coder to determine which conditions these labs are associated with as well as determining whether they are stable, improving, ect. Which I totally agree with. Here is an example of one I am having a hard time with.
Pt. presents today in f/up on labs.
Discussed labs drawn on 7/5/17
CMP: Glu 108 otherwise wnl.
A1c: 5.6
Insulin: 17
TSH: 1.33 Takes levo 137 mcg and lio 10 mcg
fT4: 0.92
fT3: 2.6
Lipids: 112/119/57/31 Takes atorvastatin 40 mg.
CBC: wnl
Pt has seen a health coach a couple of times. Will set her back up with her.
Pt. is sxic (very fatigued) and fT4 is low, fT3 is low normal.
So she listed the date the labs are drawn, can this be counted as timing? (I don't think so, but another coder counts this in our office)
Also she lists two different meds which by the looks of it is for two completely different conditions. Do I get 2 points for this for modifying factors? Or just one?
Very fatigued. I am counting this as associated signs and symptoms.
Then she reiterates that the Ft4 and Ft3 are low and low normal. Can I count this as quality?
Thank you for any help you can give. I have tried giving her pointers to make her HPI's better but she doesn't seem to make an effort.