HEDIS Coding and reporting

1. General Progress Note JANE DOE
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Patient: JANE DOE MRN: 123546 FIN: 12345
Age: 69 years Sex: Female DOB: 1/30/1947
Associated Diagnoses: History of breast cancer in female; H/O lymph node excision; Mixed hyperlipidemia; Chronic obstructive
pulmonary disease, unspecified; Osteopenia; Acute hyperkalemia; Elevated TSH
Author: GOOD DOCTOR MD
Visit Information
Date of Service: 06/28/2017 03:14 pm Performing Location: Good Doctor MD
Chief Complaint: Follow up for COPD
History of Present Illness
FEELS WELL NO COMPLAINTS OF HA, CP, ABD PAIN, LEG PAIN
Review of Systems
Constitutional: No fever, No weakness, No fatigue.
Eye: No recent visual problem.
Ear/Nose/Mouth/Throat: No nasal congestion, No sore throat.
Respiratory: No shortness of breath, No cough, No sputum production, No exertional dyspnea.
Cardiovascular: No chest pain, No peripheral edema.
Gastrointestinal: No nausea, No vomiting, No diarrhea, No constipation, No abdominal pain.
Musculoskeletal: No joint pain.
Neurologic: Alert and oriented X4, No headache.
Psychiatric: Negative.
Health Status
Allergies:
Allergic Reactions (Selected)
Severity Not Documented
FLUFFY DOGS (No reactions were documented)
Medications: (Selected)
Documented Medications
Calcium 600+D: 0 Refill(s), Type: Maintenance
Symbicort 160/4.5
Co Q-10 100 mg oral capsule: daily, 0 Refill(s), Type: Maintenance
Fish Oil 1200 mg oral capsule: daily, 0 Refill(s), Type: Maintenance
Red Yeast Rice: ( 1,200 mg ), daily, 0 Refill(s), Type: Maintenance
Vitamin B12: 0 Refill(s), Type: Maintenance
glucosamine 500 mg oral tablet: 0 Refill(s), Type: Maintenance
Caltrate 600+D
Problem list:
All Problems
History of breast cancer in female / SNOMED CT 2537677017 / Confirmed
H/O lymph node excision / SNOMED CT 251850013 / Confirmed
Flatus / SNOMED CT 397913013 / Confirmed
Let us explore the ways your progress notes could be addressing the required HEDIS quality data, but your coding is not up to par!
Most providers with electronic records
provide a list of medications being taken by
their patient, this is codeable information
needed by the health plan.
Care of older adult - medication review

2. General Progress Note JANE DOE
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Diarrhea / SNOMED CT 103576018 / Confirmed
Mixed hyperlipidemia / SNOMED CT 398859011 / Confirmed
Vitamin D deficiency, unspecified / SNOMED CT 57937016 / Confirmed
Encounter for general adult medical examination with abnormal findings / SNOMED CT 453941019 / Confirmed
Body mass index (BMI) 22.0-22.9, adult / SNOMED CT 442609010 / Confirmed
Chronic obstructive pulmonary disease, unspecified / SNOMED CT 23287019 / Confirmed
Osteopenia / SNOMED CT 456694019 / Confirmed
Body mass index (BMI) 22.0-22.9, adult / SNOMED CT 1226967010 / Confirmed
Histories
Past Medical History:
No active or resolved past medical history items have been selected or recorded.
Family History:
MI
Father
Colon cancer..
Mother
Diabetes Mellitus
Brother
Procedure history:
H/O: Hysterectomy (ICD-9-CM V88.01).
H/O mastectomy (ICD-9-CM V45.71).
History of colon surgery (ICD-9-CM V45.89).
Social History:
Alcohol Assessment: Denies Alcohol Use
Tobacco Assessment: Past
Past, Cigarettes
Physical Examination
Vital Signs
6/28/2017 4:30 PM EDT Peripheral Pulse Rate 76 bpm
Systolic Blood Pressure 112 mmHg
Diastolic Blood Pressure 70 mmHg
Mean Arterial Pressure 84 mmHg
BP Site Left arm
BP Method Manual
Oxygen Saturation 98 %
Measurements from flowsheet : Measurements
6/28/2017 4:30 PM EDT Height Measured - Standard 66 in
Weight Measured - Standard 140 lb
BSA 1.72 m2
Body Mass Index 22.59 kg/m2
General: Alert and oriented, No acute distress, appears to be the stated age.
Eye: Normal conjunctiva.
HENT: Normocephalic.
Neck: No jugular venous distention, no use of accesory muscles of respiration during quiet breathing.
Respiratory: Respirations are non-labored, decreased breath sounds.
Cardiovascular: Normal rate, Regular rhythm.
Gastrointestinal: Soft, Non-tender.
Musculoskeletal: Normal gait.
Integumentary: no cyanosis .
Neurologic: Alert, Oriented.
Psychiatric: Cooperative, Appropriate mood & affect.
Review / Management
Results review: Lab results
Similar to diagnosis codes HEDIS data is reported by specific codes,
including those for hypetension, BMI, Breast cancer screening and others
Controlling high blood pressure
Adult BMI Assesstment

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4/20/2017 3:26 PM EDT
145 mmol/L
6.1 mmol/L HI
107 mmol/L
32 mmol/L HI
98 mg/dL
13 mg/dL
0.80 mg/dL
NOT APPLICABLE (calc) 87 mL/
min/1.73m^2
75 mL/min/1.73m^2 10.0 mg/dL
0.5 mg/dL
57 U/L
17 U/L
18 U/L
7.0 g/dL
4.6 g/dL6.1
2.4 g/dL (calc)
1.9 (calc)
<8 pg/mL
58 pg/mL
44 ng/mL
<4 ng/mL
44 ng/mL
261 mg/dL HI (Modified)
89 mg/dL (Modified)
2.9 (calc) (Modified)
158 mg/dL (calc) HI (Modified)
172 mg/dL (calc) HI (Modified)
68 mg/dL (Modified)
7.3 mcg/dL (Modified)
1.1 ng/dL
90 ng/dL
4.86 mIU/L HI
5.4 thousand/uL (Modified)
4.53 million/uL (Modified)
13.4 g/dL (Modified)
40.1 % (Modified)
88.5 fL (Modified)
29.6 pg (Modified)
33.4 g/dL (Modified)
13.0 % (Modified)
226 thousand/uL (Modified)
13.0 fL HI (Modified)
43.7 % (Modified)
2,360 cells/uL (Modified)
43.0 % (Modified)
2,322 cells/uL (Modified)
9.7 % (Modified)
524 cells/uL (Modified)
1.7 % (Modified)
92 cells/uL (Modified)
1.9 % (Modified)
103 cells/uL (Modified)
DARK YELLOW (Modified)
CLOUDY (Modified)
5.5 (Modified)
1.022 (Modified)
NEGATIVE (Modified)
Sodium Level
Potassium Level
Chloride Level
CO2 Level
Glucose Level
BUN
Creatinine Level
BUN/Creat Ratio
eGFR African American
eGFR Non-African American
Calcium Level
Bili Total
Alk Phos
AST/SGOT
ALT/SGPT
Hemogobin A1c
Protein Total
Albumin Level
Globulin
A/G Ratio
Vitamin D2, 1, 25 Dihydroxy
Vitamin D3, 1, 25 Dihydroxy
Vitamin D 25 OH
Vitamin D 25-OH, D2 Vitamin
D 25-OH, D3 Cholesterol
HDL
Cholesterol/HDL Ratio LDL
Non HDL Cholesterol
Triglyceride
T4 (Thyroxine)
T4 Free
T3 Total
TSH
WBC
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW
Platelet
MPV
Neutrophils
Abs Neutrophils
Lymphocytes
Abs Lymphocytes Monocytes
Abs Monocytes Eosinophils
Abs Eosinophils
Basophils
Abs Basophils
UA Color
UA Appear
UA pH
UA Specific Gravity
UA Glucose
UA Bilirubin
NEGATIVE (Modified)
If it is noted on your record, it should be codedComprehensive Diabetes Care

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UA Ketones NEGATIVE
(Modified)
UA Blood 1+
(Modified)
UA Protein 2+
(Modified)
UA Nitrite
NEGATIVE
(Modified)
UA Leukocyte Esterase
2+
(Modified)
UA WBC
20-40 /HPF
(Modified)
UA RBC
3-10 /HPF
(Modified)
UA Squam Epithelial
6-10 /HPF
(Modified)
UA Bacteria
FEW /HPF
(Modified)
UA Hyaline Cast
4-5 /LPF
(Modified)
Culture Urine
See comment
SCREENING MAMMOGRAM 4/20/17 BIRADS 2
BONE DENSITY 4/19/16 OSTEOPENIA
CXR 4/19/16 COPD, NAI
SPIROMETRY 4/19/16
FEV1 IS 2.65=118%
FEV1/FVC 73%
.
Impression and Plan
Diagnosis
History of breast cancer in female (ICD10-CM Z85.3).
Acute hyperkalemia (ICD10-CM E87.5).
Elevated TSH (ICD10-CM R94.6).
Abnormal casts in urine (ICD10-CM R82.99).
H/O lymph node excision (ICD10-CM Z98.89).
Mixed hyperlipidemia (ICD10-CM E78.2).
Chronic obstructive pulmonary disease, unspecified (ICD10-CM J44.9).
Osteopenia (ICD10-CM M85.80).
Plan: LAB REVIEWED
NEEDS REPEAT BMP, TSH, U/A
GIVEN STOOL FOR OB
DISCUSSED TSH WITH PATIENT.
Patient Instructions: Counseled: Patient, Regarding diagnosis, Regarding treatment, Regarding medications, Verbalized
Orders
Lab (Gen Lab | Reference Lab):
Urinalysis, Complete w/Reflex to Culture* (Quest) (Order): Specimen Type: Urine, Specimen Collected Out of Office, Collection
Date: 6/28/2017 4:44 PM EDT
TSH, 3rd Generation w/ Reflex to Free T4* (Quest) (Order): Specimen Type: Serum, Specimen Collected Out of Office,
Collection Date: 6/28/2017 4:44 PM EDT
T4, Total (Thyroxine)* (Quest) (Order): Specimen Type: Serum, Specimen Collected Out of Office, Collection Date: 6/28/2017
4:44 PM EDT
T3, total* (Quest) (Order): Specimen Type: Serum, Specimen Collected Out of Office, Collection Date: 6/28/2017 4:44 PM EDT
Comprehensive Metabolic Panel* (Quest) (Order): Specimen Type: Serum, Specimen Collected Out of Office, Collection Date:
6/28/2017 4:44 PM EDT
Charges (Evaluation and Management):
99213 office outpatient visit 15 minutes (Charge) (Order): Quantity: 1, History of breast cancer in female | Mixed hyperlipidemia |
Chronic obstructive pulmonary disease, unspecified | Osteopenia | Acute hyperkalemia | Elevated TSH |
Requests (Return to Office):
Return to Clinic (Request) (Order): Return in 3 months.
Follow up sooner if any changes, problems or issues..
Signature Line
Osteoporosis Management in Women who had a Fracture
Make sure all your documentation is coded and transmitted to the health plan, your starts depend on it!
Breast Cancer Screening

5. General Progress Note JANE DOE
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Signed and Authored by GOOD DOCTOR MD on 06/28/2017 04:45 PM EDT
June 28, 2017 4:31 PM EDTCharted Date:
Subject / Title:
Performed By:
Normal General Exam *
Good Doctor, MD on June 28, 2017 4:45 PM EDT
Electronically Signed By: Good Doctor, MD