# Chronic Conditions and Prescription Drugs



## MandyFlagg (Aug 5, 2009)

I am hoping someone will be able to help me because I am not finding this anywhere.  

First - Under 97 Guidelines in the HPI you can credit them for the status of 3 Chronic Conditions, Can you give credit if they are not talking about those issues or addressing them at all in the note?  
     IE: CC: constipation
     HPI: The patient has not had a BM in 2 days and complaining of abd pain today.   HTN, DM, PVD, CHF all stable

Second - When counting "prescription drug management" in the MDM for the table of risk and "parenteral controlled substances and drug therapy requiring intensive monitoring for toxicity" does the provider need to address them or can it just be a list of the medications the patients are on.  The encounters the NP's I code for will just simply list meds (sometimes with dosage and sometimes not)  Can I credit them or not?

Third - For the Nature of the Presenting Problem how do you count that, I am doing SNF physician billing (99307-99310) and I am getting a 99310 for one skin tear, because they are actually documenting the status of the chronic illnesses and doing a full body exam but the MDM is "LLE skin tear, monitor for infection"  I do not feel right giving them this code but the documentation is there, what do I do?  

If someone knows the answer, and could lead me in the right direction of where to find this I need it for the next meeting I have to present this information.  Some of the people I have to present this to will not take my word they must have something in writing.  Please feel free to private message me, or respond.  

I THANK YOU EMENSLY FOR YOUR HELP IN ADVANCE

Mandy Flagg, CPC


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## LLovett (Aug 5, 2009)

For the 3 C's you actually have to list each and give sort of a status update in the patients own words.

Example: HTN- states home pressures are running a little high, continues to take meds but has not changed diet

COPD-complains of increased shortness of breath when walking

DM-per home log sugars are running high, but patient is still not compliant with diet modifications.

On the Rx management, a list of current meds is just past history, the provider actually has to be dealing with the drugs they are on to get credit. They don't have to change anything, but they need to indicate it was part of their MDM.

Example: HTN-stable, continue current meds

On the table of risk, it is the highest you get in any of the 3 categories. So even if your presenting problem falls under low (acute uncomplicated illness or injury) if your management option selected is Rx management, your risk is actually moderate.

Hope this helps,

Laura, CPC, CEMC


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## FTessaBartels (Aug 6, 2009)

*Agree with Laura*

I agree with Laura.
In the example you gave for case 1 ... it seemed to me that the reason for the vist was constipation. The chronic conditions seem to be listed but not addressed.

So I'd give credit for 3 elements of HPI - location, duration and associated sign.  I'd use the list of chronic conditions as ROS *- OR -* Past Medical Hx (depending on what I needed).

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## MandyFlagg (Aug 6, 2009)

I am finding that the np's think they get credit for the status of the chronic conditions no matter what the chief complain is.  I bill for 80+ NP's they all document different and they do not get the fact that they need document appropriatly, not every pt they see will be a high level visit but some are making them higher level codes because of documentation.  Is there anything documented that states they need to be addressing them?

Secondly, the prescription medications.  On our 2 page comprehensive notes they have a place to list the medications that the patient is on.  They list all of them, and sometimes do not list them in the impression and treatment plan like they are managing them.  So am I correct in stating they have to be addressing the medication to be able to count that in the MDM?

THANKS TO EVERYONE FOR ALL OF YOUR HELP!


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## LLovett (Aug 6, 2009)

In the 97 guidelines it states

"An extended HPI consists of at least four elements of the HPI or the status of at least
three chronic or inactive conditions.
!DG: The medical record should describe at least four elements of the present
illness (HPI), or *the status of at least three chronic or inactive
conditions*." 

That is on the bottom of page 7. This takes the place of elements in the HPI, but it is still the history of the present illness, not history of past illness.

The 3 C setup is for patients being treated for chronic issues, if you are treating an acute illness you should be documenting elements of HPI and the chronic issues are part of the patients past history during this visit.

I know where you are coming from on documentation from NPPs. They can drive the level really high with history and exam when it may not be justified from a medical necessity stand point. You may need to get the medical director, or whoever is over them, involved.

You are correct, the rx has to come into play in their medical decision making to count it. 

Laura, CPC, CEMC


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## MandyFlagg (Aug 6, 2009)

The unfortunate thing is I have involved the director but they always come back with I need to have it in writing, I have given multiple people the guidelines and they state that it does not state that they have to be addressed.  I see some of them documenting the conditions on EVERY encounter no matter the problem.  That is why I am needing to find something in writing that states that. I understand it and so do the other coders but they insist that since the guidelines do not state either issues I am writing about that I am wrong!


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## LLovett (Aug 6, 2009)

I'm not sure what type of practice you work at but Medicare generally sets the standard and the 97 guidelines are from Medicare.

Email your questions to your Medicare carrier. Get it in writing from them.

WPSMedicare has a lot of info on E/M, not sure if your specific questions are answered or not.

http://www.wpsmedicare.com/part_b/education/evalmngmnt.shtml

Good luck,

Laura, CPC, CEMC


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## MandyFlagg (Aug 7, 2009)

I work with 80+ NP's that work nationwide, we deal with numerous different Medicare Carriers that is why I am having trouble.  

I am sitting for the CEMC test in September and hoping that will give me more amuntion that I DO know what I am doing.  

Thank you for all of your help, it is so nice to have these forums to verify our knowledge!


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