Quick question for opinion. 95% of this pt's note was regarding his f/u for diabetes. I was told I should have included the elevated BP since the doctor is going to monitor it. Do other coders agree with counting 1 problem point for est problem stable and 3 or 4 data points for the BP as a new problem?
Thanks for your input.
Assessment / Plan
25 year old male with NIDDM currently on metformin. BP mildly elevated, previously normal, will monitor. Discussed diet modifications and check FS and keeping log. Pt. understands. Advised to call when flu shot available.
Thanks for your input.
Assessment / Plan
25 year old male with NIDDM currently on metformin. BP mildly elevated, previously normal, will monitor. Discussed diet modifications and check FS and keeping log. Pt. understands. Advised to call when flu shot available.