Forum - Questions & Answers
what needs to be in PMH follow up question
For coding a 99214, I like to use PMH rather than SH or FH. If my note must have PMH in it, can I just mention a relevant one in the HPI. For example, 57 year old with HTN seen for routine fu. Since i mentioned HTN, will that count as PMH or would I have to also mention his hyperchol, and DM2 in order to get credit for PMH?
eg:
cc: fu of chronic conditions
HPI: 56 year old taking lisnopril for HTN. no cough, no cp, no SOB. Also takes metformin for DM, compliant with no s/e and crestor for hypercholesterolemia with no myalgias. Last LDL was 76.
PMH: HTN
ROS: no chest pain, sob, myaglais, aches, arthralgia
PE: VS 120/80 HR 66 RR 16 BMI 30
Lung - cta
CVS -RRR
Ext: no edema, no carotid bruit
Labs: none
A/P:
1) HTN -controlled- cont lisniprol
2) DM2- check a1c, cont metformin
3) Hyperchol - LDL at goal - cont crestor.
4) obesity - counlsed on low fat diet.
to me, this is a 99214. Any disagreement?