Does this documentations qualifies for 99214?
HPI;Pt is here for routine f/u ...
Continue Lotrel Capsule, 10-20 MG, Orally, 30, 1 capsule, Once a day, 30 days, Refills 3
LDL is noted to be in high 180's ... pt to try lifestyle changes for now ... If he is not able to lower cholesterol on his own, then may offer statin
HgbA1C% is elevated @ 6.3% ... exercise/diet d/w pt as firstline tx for hyperglycemia
Exercise/diet d/w pt ... I have spoken with Jacop frankly how these new nedical problems, mainly high chol & high BS are both related to being overweight & may resolve if he's able to loose weight ...
May be related to early DM vs HTN ... he already takes benazepril in lotrel
My concern is this;if it's ACCEPTABLE if the Provider will not mention the chronic illnesses in the HPI BUT will state the status of those chronic illnesses in the TREATMENT PLAN like for example as stated above as: HTN =STABLE.ETC.
By the way this visit has COMPLETE ROS AND PHY.EXAM.
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