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HPI items not addressed

Good Afternoon Everyone,

CC: medication refill

HPI: Patient here for medication refills. Pt has type 2 DM, HTN, HLD, GERD. Patient reports poor compliance with meds and out of BP meds about 2 wks.

Of note; Lisinopril, Metformin and issue of repeat prescription for Prilosec. Controlled on current medication dose and regimen.

Would you consider the following a true statement in regards to this scenario?

"You must document the conditions you didn’t address (eg; HLD and chronic pain not addressed during this encounter")

Thank you for your time
Lyn

Medical Billing and Coding Forum