# HPI for F/U visit for elevated BP



## dballard2004 (Mar 23, 2010)

How many elements of HPI do you see here, please?

CC: Pt here for follow-up visit for recheck of blood pressure

Other: I was seen 2 weeks ago for a sore throat and my blood pressure was high.  I was told that I should come back and have it checked.  I feel fine.

HPI: Pt noted to have elevated blood pressure at previous visit.


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## FTessaBartels (Mar 23, 2010)

*Context and qualify*

If I am interpreting your scenario correctly ... Since you can only count what the PROVIDER documented (not what the patient wrote) ...

Context (on previous visit)
Quality (elevated)


F Tessa Bartels, CPC, CEMC


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## dballard2004 (Mar 23, 2010)

Thanks.  I don't even know why the "other" part was in the note anyway.  It is just a part of our EMR that allows patients to enter this kind of info when they check-in.


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## dballard2004 (Mar 23, 2010)

Another question.....this was a follow-up visit for elevated BP and the patient's BP was elevated on this visit as well and the provider recommended another follow-up visit.  I assigned low risk here but one of my coders is questioning this.  She feels that this should be minimal risk since no OTCs were given and no medications were prescribed.  I think low is appropriate since the pressure is elevated and the provider wants the patient to follow-up.  Would I be safe to assume that if a follow-up visit is recommended for something like this since the patient has already presented twice with the elevated BP, that low risk is correct?  Thanks.


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## FTessaBartels (Mar 23, 2010)

*Table of risk*

Your risk is the "HIGHEST" level you get from the 9 boxes on the table.  

So if you had an acute, uncomplicated illness  (low risk) but prescribed a drug for treatment (moderate risk) you would have Moderate Risk. 

Although I can't tell if patient has been diagnosed with HTN from the brief example, I would be willing to listen to arguments for Moderate Risk (one or more chronic illnesses with mild exacerbation / progression)

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## dballard2004 (Mar 24, 2010)

Thank you so very much!


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