Go Back   AAPC Forum > Medical Coding > General Discussion
Forum Rules FAQ Members List Calendar Search Today's Posts Mark Forums Read

Thread Tools
Old 05-23-2012, 05:42 AM
venkatbpt2000 venkatbpt2000 is offline
Join Date: Apr 2007
Posts: 3
venkatbpt2000 is on a distinguished road
Default HPI Element - Modifying Factor


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
Reply With Quote
Old 05-23-2012, 06:41 AM
mitchellde's Avatar
mitchellde mitchellde is offline
True Blue
Join Date: Apr 2007
Location: Columbia, MO
Posts: 11,070
mitchellde will become famous soon enoughmitchellde will become famous soon enough

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
Reply With Quote
Old 05-23-2012, 12:43 PM
ollielooya ollielooya is offline
True Blue
Join Date: Apr 2007
Location: Everett, WA
Posts: 869
ollielooya is on a distinguished road

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
Reply With Quote
Old 05-23-2012, 01:30 PM
Cyndi113's Avatar
Cyndi113 Cyndi113 is offline
True Blue
Join Date: Apr 2007
Location: Phoenix, AZ
Posts: 620
Cyndi113 is on a distinguished road

Well put Suzanne. I agree with you Debra!
Cyndi Allen, CPC, CIRCC
2015 Local Chapter President, Casa Grande, AZ

Last edited by Cyndi113; 05-23-2012 at 01:31 PM. Reason: correct punctuation
Reply With Quote

Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off

Disclaimer: Although AAPC staff members will monitor these forums periodically, we cannot be responsible for the information posted herein, nor guarantee its accuracy. Our members may discuss various subjects related to medical coding, but none of the information should replace the independent judgment of a physician for any given health issue. Please note that the opinions expressed here do not necessarily reflect those of AAPC.

All times are GMT -6. The time now is 08:18 PM.

Powered by vBulletin® Version 3.8.1
Copyright ©2000 - 2015, Jelsoft Enterprises Ltd.
Copyright ?2015, AAPC