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I have a patient encounter assessment that states, "Hyperlipidemia with severe hypertriglyceridemia on moderately high doses of niacin and Zetia," and I was wondering if you report E78.2 (mixed hyperglyceridemia) even though the patient encounter doesn't state this diagnosis. However, the patient encounter's lab results state that the lab results showed elevated cholesterol and triglyceride levels. Also, since niacin and Zetia do not have long-term use codes, do I report Z79.899, since these drugs are stated in the assessment as described? These medications are also listed in the medication list as well. In addition, the patient encounter states, "GASTROINTESTINAL: Abdomen: Central obesity," and this is the only place that obesity is mentioned. I assume that since obesity is not specifically mentioned as being a part of the medical decision making for the following assessment, I do not report the obesity, E66.89.
In others, do I report E78.2 (mixed hyperglyceridemia), G47.33 (obstructive sleep apnea), Z95.2 (presence of heart valve), Z79.01 (long-term use of anticoagulant, coumadin), and Z79.899 (other long-term current drug therapy - niacin and Zetia)?
ASSESSMENT
1. Four and one-half years S/P mechanical aortic valve replacement for severe aortic stenosis.
2. Hyperlipidemia with severe hypertriglyceridemia on moderately high doses of niacin and Zetia.
3. Mild obstructive sleep apnea CPAP.
4. Coumadin daily
Thank you for your help.
In others, do I report E78.2 (mixed hyperglyceridemia), G47.33 (obstructive sleep apnea), Z95.2 (presence of heart valve), Z79.01 (long-term use of anticoagulant, coumadin), and Z79.899 (other long-term current drug therapy - niacin and Zetia)?
ASSESSMENT
1. Four and one-half years S/P mechanical aortic valve replacement for severe aortic stenosis.
2. Hyperlipidemia with severe hypertriglyceridemia on moderately high doses of niacin and Zetia.
3. Mild obstructive sleep apnea CPAP.
4. Coumadin daily
Thank you for your help.