Endocrinology HPI and Exam

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

Moderators: Shannon DeConda, NAMAS Moderator

Post Reply
Shoshana
Posts: 73
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Thu Oct 11, 2018 2:10 pm

Can someone help me with the HPI Level:
1. Secondary Hyperparathyroidism. due to Vit D insufficiency. He has been taking vitamin d 50,000 units twice per week. He denies any compressive symptoms, no broken bones, no kidney stones, no abd pain.
2. Impaired fasting glucose - A1c 5.6
2. MNG noted with recent ultrasound. normal thyroid function test.
3. Fat Malabsorption - unclear reason with fatty greasy floating stool persisting no discomfort. On Creon 36,000 2 pills with each meal. too expensive (Digest Gold - nutrition store)
4. Back fusion recent surgery march 2018 and "has all fused" wearing a back brace no current back pain. Last DEXA was October 2017 with Osteopenia.

Also, would anyone give any credit for this Physicial Exam:
Vitals taken xx/xx/xx 00:00
rbs-100
BP sitting 128/73
BP cuff size regular
Pulse rate sitting 54 bpm
Height 70.5 in.
Weight 169lbs 8 oz
BMI 24.0 kg/m2
Body Surface Area 1.96 m2

(This is exactly like the chart including punctuation and misspellings)
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
User avatar
admin
Site Admin
Posts: 431
Joined: Mon Apr 09, 2012 1:54 pm

Wed Oct 17, 2018 10:54 am

Without a clear date and time, the vitals documented in the second half of the question below can’t be credited. If there is a date and time, this counts as a Constitutional system under 1995 guidelines, or as one bullet under 1997.

For 1997, this would qualify as the status of three chronic conditions. For 1995, I count Severity (A1c reading), Modifying factors (Vitamin d and Creon) and associated signs and symptoms (no back pain, no compressive symptoms). The stools for the fat malabsorption would be an associated sign and symptoms, but the Quality bullet only applies to the sign and symptom, and not the condition itself.

Your question has been answered by J. Paul Spencer, CPC, COC
Shoshana
Posts: 73
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Thu Oct 18, 2018 11:23 am

Thank you for your response. I have been told FCSO in Florida does not accept negatives as Associated Signs and Symptoms. Those must be counted in ROS. Is this true?
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
User avatar
admin
Site Admin
Posts: 431
Joined: Mon Apr 09, 2012 1:54 pm

Thu Oct 18, 2018 12:19 pm

Hello,

It is true, but in this particular case, if you use the 1995 guidelines, you can use the stools for AS&S for the fat malabsorption.

J Paul Spencer
Shoshana
Posts: 73
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Thu Oct 18, 2018 1:31 pm

Thanks for your prompt response, Paul. Appreciate it.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Post Reply