Wiki Status of three chronic illnesses

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lisavalentin

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Hi!

I am new to urology coding.

This is my doctor's HPI: "Patient is a 67 y/o male with type 2 NIDDM and essential hypertension, both of which have been fairly well controlled with current medications. He has also been diagnosed with prostate hypertrophy with urinary frequency as an associated symptom which has improved with Flomax 0.4 mg."

His ROS, PFSH and PE are outstanding...all qualify for a 99214. The MDM is not of moderate complexity but I believe he does have something in his HPI.

My question is: Can the status of the patient's HTN and DM be considered along with his BPH as 'status of three chronic diseases'?

I mean, don't all of the illnesses have to be related to urology given his specialty?

I really have no idea and would appreciate any help.

Thanks in advance!
 
yes. HTN and DM can be considered for chronic illness. but BPH cannot be considered.

so in this case you can consider WELL CONTROLLED as SEVERITY.

according to me, in this given scenario, documentation does not support for 3+ chronic conditions.
 
Is the urologist treating the HTN? The diabetes? If it's a complication or consideration of the presenting problem, then it can't be counted separately. If the provider is not treating the condition, then you cannot count it in your HPI.

Why was the patient there? What is the nature of the presenting problem? If you're auditing a urologist, I highly doubt they are taking over the treatment of the DM....it may be a consideration in terms of the plan for the presenting problem and may contribute to Risk (and MDM), but it doesn't mean they're treating the DM. The point of "update of three chronics" means that the provider is treating three chronic conditions, and updates them separately in his HPI, along with reporting the associated ROS, the relevant exam and the individual assessment/plan for each chronic.

Be careful to not get caught up in "counting bullets". The conditions that are reported have to be addressed throughout the progress note and have to be medically necessary from the specialists' perspective.
 
I would have given 4 for HPI:

Location-GU-prostate BPH
Assoc Signs and Symptoms-urinary frequency
Severity-Improved
Modifying Factors- Flomax 0.4 mg

Just another opinion....
 
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