Question about Hyperlipidemia / hypertriglyceridemia and dosage coding

[crbm71@gmail.com]

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.

 

[thlynn2023@gmail.com]

NEVER diagnosis a patient off of labs; query the provider. If the documentation doesn't specifically state "chronic" then follow ICD guidelines and code for acute. If there isnt a definitive diagnosis only the S&S are coded.
If it isnt documented it didn't happen.
Only code a diagnosis that is being treated. Some of my providers list 20 diagnosis without treatment, doing so doesn't add to the MDM.
What condition, what was done and why are the questions I ask myself.
You can use Z79.899 for zita use and Z79.01 for reporting current coumidin use. I would add Z51.81 to show that those meds are being managed or assess. Leave obesity alone if nothing was done, same with any other diagnosis left untreated.