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Help with determining History type

  1. #1
    Question Help with determining History type
    Medical Coding Books
    If a patient is coming in to discuss lab results, has a new dx, such as hypothyroidism for which they are given a script for thyroid replacement. I've got: "here to follow-up lab results," VS were obtained, noted no allergies, date of LMP, and a note "well-nourished, well-developed, no apparent distress, afebrile, BMI out of recommended rnge, Class I obesity with BMI 32.1.

    I have a review of 3 systems (constituitonal, endocine and allergy), also that pt does not smoke (social hx). What level hx would you call that?

    Thanks in advance!

  2. #2
    Because the patient is only coming in to discuss lab results, I would say that the hypothyroidism is a brief HPI. You have a detailed ROS and PFSH, but you can only use an expanded problem focused History due to the HPI elements. That is just my take on it. Hope that helps.

    I would code a 99213 - exp prob foc HPI, Exam not needed, and a moderate MDM due to the New dx with work up and chronic illness with mild exacerbation.
    Last edited by krssy70; 01-04-2010 at 10:59 AM.
    Kristen Richard, CPC

  3. #3

    Thank you! That is how I have been looking at it, but just wanted to doible-check myself.

    Thanks again!

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