Brandi -- Sorry, I know it is Christmas eve...but where did you get Hyperlipidemia? I was looking for it.
I was trying to figure out what I was talking about when I told you that...turns out I can't. Ha! I must have gotten distracted and mixed up details from something else - Let me see if I can give a coherent answer this time...
Okay, for Headache Guy:
I see where the 3 chronic conditions came from - I got these: HTN, Type II Diabetes, PVC
(ACTOS is a prescription medication used with diet and exercise to improve blood sugar (glucose) control in adults with type 2 diabetes.)
And I think I meant to say hyper
glycemia, and my brain locked on hyperlipidemia instead; I don't know why I was even thinking about it then, because he doesn't have it. But, his "poor glycemic index" is an indication of mild progression in a chronic condition, in addition to 2 stable chronic conditions. The only new problem is the headache, which is, apparently, a side effect of his HTN treatment. The lack of notation on the diabetes makes it seem like another doctor might be responsible for his diabetic management. If that's not the case, this doctor really needs to write more; but if it is, I'm not confident that the diabetes is significant in calculating this particular MDM.
The notes have room for improvement (a LOT of room). I do see what you're saying about it being baffling, and I don't think a 99214 would hold up in an audit - There's literally
barely enough documentation to support a Detailed history and Moderate MDM, and it's vague, disconnected, and it skips through an undetermined period of time. I also find the focus of the record odd - If I were in the doctor's shoes, I'd take better care to ensure that my involvement and intent were conveyed more decisively, so that neither could be misconstrued by anyone - whether in an audit or in legal proceedings.
What's missing from the note is more interesting than what's in it. There's no indication as to why the patient had "tried a [higher dosage]" of metoprolol in the first place. Was it prescribed, or self-adjusted? When did the increase occur? When did he call the doctor about it? Since it was effective in treating his HTN and PVC, how are those conditions going to be affected by tapering off the metoprolol? Will an alternative therapy be needed, or has the patient spontaneously recovered enough to no longer require the use of prescription medications? Tapering the dosage so drasticly, with no apparent intent to continue with the treatment, is a medical decision that requires more elaboration to clarify the rationale behind it, in my opinion. According to
Wikipedia, headaches aren't a side effect associated with Metoprolol; it's even indicated for the treatment of migraines. There's risk of serious side effects, but many of the identifying risk factors (especially for diabetics), like swelling of the extremities, weren't documented as reviewed - which is not to say that they weren't. It just seems irresponsible to omit so much relevant information. You'd be hard pressed to appeal an adverse determination with so little to go on.
Anyways...don't put too much faith in me - I'm still learning things, myself, so I'm wrong about things all the time.
I try to answer to the best of my knowledge, to find out where my knowledge needs to get better. (There's a breakdown of how I got Detailed Hx)
Pain location: Headache *ROS Neurologic
Pain Scale: 1 *Would be HPI severity if it were documented by the doctor, and not a nurse or other staff.
Follow up on Headache and HTN. Chief Complaint
Allergies: Adhesive, Metformin, Ace Inhibitors *Past History
He tried increasing metoproiol to 150mg bid with increase in HA noted. *HPI Context or Assoc. Signs/Symptoms
He called me by phone and I advised tapering metroproil down to current dosage of 50mg bid, which he has noted has helpd his HA to about 30 percent of prior severity. *HPI Modifying Factors and Severity
He said at it worst the HA feels like "a whack on the head." *HPI Quality
He does note that metropriol was also helpful in PVC Tx. *ROS CV, but it's a stretch.
His glycemic index is poor. Fasting glucose is is around 140, pm glucose is 120-140. *ROS Endocrine
Meds: Cozaar, Actos, Metroproli
Phys Exam:
GEn: Obese man in no distress
HEENT: Temporal arteries nontender; Oropharnyx is benign.
Lungs: Clear to asculation and percussion.
IMpression: 1) Headache -- He is improved with with reduction of metroilol. Will continue to taper metroprioil by 50% every 10 days. Reassessment in a month.
2) HTN -- See recommendations to taper off metroprioil. Reexam in a month