A patient comes in for pruritus. HPI states info regarding that symptom. Detailed exam is done as patient also has hypertensive kidney disease and DM. Those two issues are discussed in the assessment and plan. The provider billed out a 99214 and one coder wants to down code because the prov did not list the chronic diseases in the HPI
this is the hpi:
History of Present Illness
Patient is 78-year-old female who is coming in today with complaints of itching. She reports that she has itching mostly that is worse at night. She has a history of itching particularly when she is very anxious. If this is caused her to have significant insomnia. She has tried hydroxyzine with no resolution of her symptoms. She denies any chest pain or shortness of breath. He denies any particular areas of a rash.
Note the patient also has a history of a gastric polyp and also non-Hodgkin’s lymphoma. The patient reports to me that she has been recommended by her oncologist to have a repeat EGD. However the patient is very anxious about having this repeated as she had complications after her last EGD. As of now the patient has made a decision not to have a repeat EGD. However per the reports that I am reading the mass has grown daily double in size in her abdomen.
and this is the assessment/plan
Assessment/Plan
1. Pruritus
This may be secondary to anxiety given her current illnesses. I will try her on triamcinolone lotion to see if this will help with the pruritus. We will also treat her with Ativan low dose to see if this will help with some of anxiety as well.
2. HTN – Hypertension
Stage II today. We will continue to monitor
3. Chronic kidney disease
Aware. There are no new changes. She is aware that she cannot take any anti-inflammatory therapy.
4. History of gastric polyp
As noted above. She has clotting EGD for now.
5. Non-Hodgkin lymphoma
Followed at the cancer center.
6. Type 2 diabetes mellitus
Her last hemoglobin A1c was 8.3%. She is on insulin therapy. We will continue to monitor her glucose and also encouraged her to modify her diet. Follow-up in several weeks