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HPI Element - Modifying Factor

  1. Default HPI Element - Modifying Factor
    Medical Coding Books

    As Per Guidelines,

    Modifying Factor- A description of steps taken by the Patient or things that make the Symptom(s) better or worse.

    For following conditions Can we take DRUGS as Modifying Factor ?

    on lisinopril, Continue BP monitering.

    2. Diabetes
    Continue MetforminHbA1c -6,

    3. In Pre-OP Visits,

    52 Y f here for pre op evaluation- Bartolin gland removal. Pt feels wells she denies fever, chills, cough, sob, cp, palpitation, N.V.D,. GU symtoms. PT denies MI, stroke, angina in the past .

    Medical h/o- Hypothyroidism, HTN , Uterine fibroids , Surgery- uterine suspension

    Allergy- nkda,

    Meds- amlodipine . Levothyroxine Diclofenac a

    Labs- hgb 11.9 PLT-229 tsh 0.78 CR-0.6 , Chest x ray may 2012---normal

    EKG may 2012 - Sinus Bradycardia ---

    PE- Stable Vitals , AAOX3, no focal deficit , Chest- b/l air entry, no added sounds
    Heart- s1s2 Sinus brady systolic murmur+, Abd- benign , Ext no edema no calf tenderness
    A/P - Pt meets low risk for proposed surgery , Recommend- D/c diclofenac, do not take nsaids, asa 5 days before surgery

    - take amlodipine and synhtroid on day of surgery
    - early ambulation, adequate hydration ,

    Dvt Prophylaxis

  2. #2
    Columbia, MO
    In this case I woulkd say no since the HTN and diabetes were not presenting symptoms. For a modifying factor it would be more like .. patient with chest pain took an aspirin before coming to the office. or pt with severe pain took tylenol prior to coming in. OR the reverse if the patient had stopped taking a med whichmade the condition worse.
    But for a patient to have no issues and just take the meds as directed to me is not a modifiying factor.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Everett, WA
    Debra, as usual, thanks for your valued input. Before reading your response I was going to answer this question, but you supplied the better answer, so all I can add is that I agree!
    Suzanne E. Byrum CPC

  4. #4
    Phoenix, AZ
    Well put Suzanne. I agree with you Debra!
    Last edited by Cyndi113; 05-23-2012 at 01:31 PM. Reason: correct punctuation
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

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