Wiki Cc/hpi

[britbrit852003]

I have a question about CC/HPI matching your MDM:
Here is my CC and HPI:

CC: medication check.

History of Present Illness:
pt. cont on lisinopril 20mg qd and hctz 25mg qd also simvastatin 80mg qd
feels well no concerns noted bp checks 130-140s/ 90s

Here is my MDM:

Problem # 1: HYPERTENSION-BENIGN (ICD-401.1)
d/c lisinopril new erx sent refill given hctz
The following medications were removed from the medication list:
Lisinopril 20 Mg Tabs (Lisinopril) ..... One by mouth daily

His updated medication list for this problem includes:
Hydrochlorothiazide 25 Mg Tabs (Hydrochlorothiazide) ..... One by mouth daily
Irbesartan 300 Mg Tabs (Irbesartan) ..... Take one by mouth daily

Problem # 2: HYPERCHOLESTEROLEMIA (ICD-272.0)
lab done erx sent
His updated medication list for this problem includes:
Simvastatin 80 Mg Tabs (Simvastatin) ..... One tab daily


My lead auditor says that the CC and HPI should be appended with the actual conditions and why they are taking the medications.
I want to see what other people think.

 

[mitchellde]

I disagree you have what you need the principle dx code here is the V58.83 followed by the appropriate V58.6- codes.
The CC is very clear the patient is returning as requested by the physician for a med check. This is a low level visit.

 

[britbrit852003]

So do you accept "Medication check" as an appropriate CC?

 

[mitchellde]

yes it states why the patient is here. The patient is the one that determines the CC for the visit, it is in their words. So "I am here for a medication recheck" is a perfectly allowable CC. Some do not like using a V code for encounters and want a diagnosis as the CC to keep from using a V code. This not good logic and is often incorrect.