donnalynn
Contributor
Hello All,
I would like your input please. There is a difference of opinion regarding the scenario below on whether you can count "new problem, with no additional work-up planned" and ALSO count "new problem, with additional work-up planned" on the same encounter. The example is at the bottom but I included the details of the chart for review.
CC: “Shortness of breath.”
HPI: Patient is a 68 year old male with a history of CHF who presents with SOB. He states this problem began about two weeks ago. The shortness of breath may occur at rest or with exertion. The timing is described as intermittent. His breathing is worse when laying flat. He has noticed his shortness of breath is often associated with worsening lower extremity swelling. He states he has a history of heart disease, but had a “negative” nuclear stress test approximately one year ago.
Medications
Atenolol 25 mg PO QD
Glyburide 5 mg PO BID
Lisinopril 10 mg PO BID
Atorvastatin 20 mg PO QD
PMH : per HPI, plus osteoarthritis and dyslipidemia
ROS :Complete ROS was performed and documented and was positive for intermittent lower extremity edema and easy bruising. For more details, please refer to the ROS questionnaire with today's date located in the chart.
FH: Mother died in her 80s of “old age”; father at age 72 of pneumonia. The patient has three grown children in good health.
SH: The patient has been married for 45 years. He denies tobacco or alcohol abuse and continues to drive himself around.
Physical Exam
Vitals: 130/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclera, moist conjunctiva; no lid-lag; PERRLA
HEENT: AT/NC; oropharynx clear with MMM and no mucosal ulcerations; auditory canals patent with pearly TMs normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules
Psych: Appropriate affect, alert and oriented to person, place and time
Labs: HGBA1c 6.8; BUN 25, creatinine 0.8; LDL 88, HGB 12
Assessment
1. Significant shortness of breath
2. Well controlled HTN
3. Optimally controlled NIRDM
4. Stable dyslipidemia
5. Stable CAD
Plan
1. Will add Lasix 40 mg PO qd
2. Will contact his former physician to obtain records of recent stress test
3. Will check a CXR today to rule out pneumonia
4. Will order an ECHO as well to quantify his EF
5. Return visit next week
6. Will check repeat HGBA1c, CBC, and renal profile
7. Will also check LFTs since patient is on statin medication
8. Will also check spot microalbumin/creatinine
Problem Points:
In the example above, the clinical problems would be scored as follows:
Problems Points
Self-limited or minor (maximum of 2)
Established problem, stable or improving
Established problem, worsening
New problem, with no additional work-up planned (maximum of 1) - X
New problem, with additional work-up planned - X
Total Problem Points = 7
Three points are scored for the "new" problems of HTN, diabetes, dyslipidemia, CAD for which no further workup is planned (max of one problem for this category). Four points are given for the "new" problem of CHF because further workup is ordered. This adds up to a total of seven problem points.
I would like your input please. There is a difference of opinion regarding the scenario below on whether you can count "new problem, with no additional work-up planned" and ALSO count "new problem, with additional work-up planned" on the same encounter. The example is at the bottom but I included the details of the chart for review.
CC: “Shortness of breath.”
HPI: Patient is a 68 year old male with a history of CHF who presents with SOB. He states this problem began about two weeks ago. The shortness of breath may occur at rest or with exertion. The timing is described as intermittent. His breathing is worse when laying flat. He has noticed his shortness of breath is often associated with worsening lower extremity swelling. He states he has a history of heart disease, but had a “negative” nuclear stress test approximately one year ago.
Medications
Atenolol 25 mg PO QD
Glyburide 5 mg PO BID
Lisinopril 10 mg PO BID
Atorvastatin 20 mg PO QD
PMH : per HPI, plus osteoarthritis and dyslipidemia
ROS :Complete ROS was performed and documented and was positive for intermittent lower extremity edema and easy bruising. For more details, please refer to the ROS questionnaire with today's date located in the chart.
FH: Mother died in her 80s of “old age”; father at age 72 of pneumonia. The patient has three grown children in good health.
SH: The patient has been married for 45 years. He denies tobacco or alcohol abuse and continues to drive himself around.
Physical Exam
Vitals: 130/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclera, moist conjunctiva; no lid-lag; PERRLA
HEENT: AT/NC; oropharynx clear with MMM and no mucosal ulcerations; auditory canals patent with pearly TMs normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules
Psych: Appropriate affect, alert and oriented to person, place and time
Labs: HGBA1c 6.8; BUN 25, creatinine 0.8; LDL 88, HGB 12
Assessment
1. Significant shortness of breath
2. Well controlled HTN
3. Optimally controlled NIRDM
4. Stable dyslipidemia
5. Stable CAD
Plan
1. Will add Lasix 40 mg PO qd
2. Will contact his former physician to obtain records of recent stress test
3. Will check a CXR today to rule out pneumonia
4. Will order an ECHO as well to quantify his EF
5. Return visit next week
6. Will check repeat HGBA1c, CBC, and renal profile
7. Will also check LFTs since patient is on statin medication
8. Will also check spot microalbumin/creatinine
Problem Points:
In the example above, the clinical problems would be scored as follows:
Problems Points
Self-limited or minor (maximum of 2)
Established problem, stable or improving
Established problem, worsening
New problem, with no additional work-up planned (maximum of 1) - X
New problem, with additional work-up planned - X
Total Problem Points = 7
Three points are scored for the "new" problems of HTN, diabetes, dyslipidemia, CAD for which no further workup is planned (max of one problem for this category). Four points are given for the "new" problem of CHF because further workup is ordered. This adds up to a total of seven problem points.
