# Chief Complaint "H/O DM2"



## heatherwinters (Feb 13, 2008)

A new patient presented today to the clinic.  The only documentation I have a chief complaint is "H/O DM2".  Under HPI, I have a number of problems documented.  Can I use this to code an E/M and draw from the HPI or do I have to code as a new patient preventative visit?


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## carafry (Mar 11, 2008)

*it depends....*

What was the focus of the visit?  Was the patient there to discuss their hx of DM and discuss on-going care?  If so, you would choose an E/M code based on the level of hx, exam and decision making.  If the patient was there for routine screenings and an overall check-up but without specific detailed discussion of diabetes, it is probably a preventive.


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## rthames052006 (Mar 14, 2008)

Heather,

Is there any documentation about what med pt is taking for the DM2.  Did the dr address any of the "documented problems" or give a status of those problems.

Roxanne Thames, CPC





heatherwinters said:


> A new patient presented today to the clinic.  The only documentation I have a chief complaint is "H/O DM2".  Under HPI, I have a number of problems documented.  Can I use this to code an E/M and draw from the HPI or do I have to code as a new patient preventative visit?


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