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HPI for F/U visit for elevated BP

  1. #1
    Location
    Overland Park, KS
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    1,166
    Default HPI for F/U visit for elevated BP
    Exam Training Packages
    How many elements of HPI do you see here, please?

    CC: Pt here for follow-up visit for recheck of blood pressure

    Other: I was seen 2 weeks ago for a sore throat and my blood pressure was high. I was told that I should come back and have it checked. I feel fine.

    HPI: Pt noted to have elevated blood pressure at previous visit.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Context and qualify
    If I am interpreting your scenario correctly ... Since you can only count what the PROVIDER documented (not what the patient wrote) ...

    Context (on previous visit)
    Quality (elevated)


    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 03-23-2010 at 03:42 PM.

  3. #3
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Thanks. I don't even know why the "other" part was in the note anyway. It is just a part of our EMR that allows patients to enter this kind of info when they check-in.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  4. #4
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Another question.....this was a follow-up visit for elevated BP and the patient's BP was elevated on this visit as well and the provider recommended another follow-up visit. I assigned low risk here but one of my coders is questioning this. She feels that this should be minimal risk since no OTCs were given and no medications were prescribed. I think low is appropriate since the pressure is elevated and the provider wants the patient to follow-up. Would I be safe to assume that if a follow-up visit is recommended for something like this since the patient has already presented twice with the elevated BP, that low risk is correct? Thanks.
    Last edited by dballard2004; 03-24-2010 at 06:34 AM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Table of risk
    Your risk is the "HIGHEST" level you get from the 9 boxes on the table.

    So if you had an acute, uncomplicated illness (low risk) but prescribed a drug for treatment (moderate risk) you would have Moderate Risk.

    Although I can't tell if patient has been diagnosed with HTN from the brief example, I would be willing to listen to arguments for Moderate Risk (one or more chronic illnesses with mild exacerbation / progression)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  6. #6
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    Thank you so very much!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

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