Would you mind looking at another one for me, it is kinda different as are many of these I am posting.

HPI: He complains of left hip pain with activity such as walking or shoveling. He thinks ED started at the same time of his hip surgery. He has a normal libido. He is interested in meds for ED. He thinks that fasting blood glucoses are ranging about 170 to 150. Denies polyuria or polydipsia. I just looking for just a HPI level here.

And, the MDM: 1) DM. Suspect control will be poor. Need f/u glycohemoglobin and urine micro alubumin. He may need to add sulfourea to regimen to achieve glycemic control. 2) HTN. Control is good. Will continue same antihypertensive regimen. Need clarification on atenolol usage.
3) Actinic Keratosis. With pts consent, 6 keratoses were destroyed using liquid nitrogen dual freeze technique.
4) Dyslipidemia. Needs F/u lipid panel to monitor gemfibrozil use.

I alread know the CPT code for the Karatosis. I am just looking for the MDM level. Thoughts? Feedback??