# HPI and 1995 guidelines-Can anyone clairify



## Love Coding! (Nov 25, 2009)

Hello,

Can anyone clairify for me what Medicare means by this statement?  How do you use the co-morbids if you cannot come up with an extended HPI under 95 guidelines?

Per the Medicare 1995 documentation guidelines:

An extended HPI consists of four or more elements of the HPI.

!DG: The medical record should describe four or more elements of the present
illness (HPI) or associated comorbidities.


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## RebeccaWoodward* (Nov 25, 2009)

Are you referring to the 3 Chronic Conditions?

If the patient has 3 chonic conditions, you can use those conditions in place of the HPI elements.  The provider needs to document those 3 chronic conditions and their *status*....Example:

Patient has history of HTN, DM, and Hyperlipidemia. Patient monitors BP weekly. Her typical BP reading is 120/85.  Her Blood pressure is adequatley controlled with Toprol.  Patient also checks insulin level daily.  Patient's takes glucophage as directed.  Patient is on a weight maintance plan and takes Crestor as directed.  Patient does not experience any negative effects of this medication.

Now...I noticed you mentioned the 95 guidelines.  I assume that your carrier allows you to use the 3 chronic conditions for the 95 DG.  The 3 chronic conditions guidelines are referenced in the 97 DG.  Recently, I wrote my local carrier and they indicated that they recommend using the 3 chronics for the 97 only.


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## Love Coding! (Nov 25, 2009)

Thank you so much for your quick reply!  My providers use the 95 guidelines.  I was confused because I know that the 97 guidelines allow you to use 3 chronic or inactive conditions, however, the 95 guidelines state the use of 4 elements needed for an extended HPI or *co-morbidities*(that is what is throwing me off) why would they state that if we cannot use them?

Thanks :0)


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## Love Coding! (Nov 25, 2009)

http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf

Page 6 in regards to HPI and 95 guidelines


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## RebeccaWoodward* (Nov 25, 2009)

95=An extended HPI consists of four or more elements of the HPI.

!DG: The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.

97=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.*

Now...

*What are the differences between the 1995 and the 1997 E/M guidelines?*

*Answer: Unfortunately, this is a complicated question and the answer may depend upon who you ask. *

The best way to consider this question is to take apart the key components of documentation.

HISTORY: The rules for documenting the PAST MEDICAL, FAMILY and SOCIAL HISTORY and REVIEW OF SYSTEMS are identical for both the 1995 amnd 1997 E/M guidelines. The sole difference lies in the documentation of the HPI. The 1995 rules state that you must use the HPI elements to complete the HPI. A BRIEF HPI requires one to three of the HPI elements while an EXTENDED HPI requires at least four HPI elements. But, there is some language in the 1995 rules that also leaves the door open to documenting an EXTENDED HPI by commenting on four "associated co-morbidities." To be honest, it's not really clear if you can use the co-morbidities or if you have to use the HPI elements when completing the HPI using the 1995 rules. *On the other hand, the 1997 E/M guidelines clearly state that you can qualify for an EXTENDED HPI by documenting four HPI elements OR by commenting on "the status of three chronic or inactive conditions."*

http://emuniversity.com/FAQ/EMFAQ3.html


95's are vague as indicated above...That's why I wrote my carrier for their view.


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## Love Coding! (Nov 25, 2009)

Thank you Rebecca for that answer, my providers are using 95 guidelines and always have.  It just gets so frustrating when there are so many shades of gray...

I appreciate your time, happy holidays!

dscoder74


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## RebeccaWoodward* (Nov 25, 2009)

I agree.  As CMS continues to make "changes", maybe this will be crystal clear one day.  Below are some Q/A from other carrier sites.  There are several that do allow the 3 Chronic Conditions with '95. 

~Happy Thanksgiving to you as well~


*Can one utilize the status of 3 chronic conditions when using the 95' DG?*

Per CMS, yes. Although this information is physically present in the 97' DG it is also implied in the 95'DG.

http://www.wisconsinmedicalsociety.org/education/faq#q22

*What is meant by "Status of chronic conditions"?*
In 1997 the Evaluation and Management (E/M) Guidelines were enhanced under the History of Present Illness (HPI) section of the 1995 score sheet to include patient's chronic conditions in which an exacerbation may have occurred resulting in the chief complaint and the reason for the patient encounter. The documentation in the patient's medical record must state a status of the chronic condition in order to meet the requirement under the History: HPI Status of 1, 2, or 3 Chronic Conditions on the 1995 scoresheet. An example could be: hypertension - stable on Atenolol.


https://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#7


*Where can I get CMS' documentation stating three chronic or inactive conditions apply to both 95 and 97 guidelines?*

A 7. The 1997 DG state an extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions. The 1995 DG do not have this statement. However, WPS Medicare received clarification from CMS indicating this statement applies to both 1995 and 1997

http://www.wpsic.com/medicare/part_b/education/evalmngmntqahistory.shtml


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## Love Coding! (Nov 25, 2009)

Hi Rebecca,

That is my hope to thank you so much for your feedback, you have been very helpful. :0)

dscoder74


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## LindaEV (Nov 25, 2009)

What if all the doctro writes is "visit for diabetes follow up"? Does this count as any HPI?


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## RebeccaWoodward* (Nov 30, 2009)

This almost sounds like a chief complaint


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## LindaEV (Nov 30, 2009)

Rebecca, I agree...but this is what I have:

Active Problems:
DM type II
Hypertension Benign
Hyperlipidemia

Chief Complaint:
Medication f/u

Reason for Visit:
visit for hypertension follow up and visit for diabetes follow up

HPI:
Mr. Smith is 57 years old.
no headache,no epistaxis,no chest pain, no polyphagia,no polydipsia

So you can see my problem....He needs "statuses" on those active problems!
The HPI is only a ROS!

I am auditing, and grasping at straws looking for something I can count as HPI....education is definitely in the works...


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## RebeccaWoodward* (Nov 30, 2009)

LINDALOUH said:


> Rebecca, I agree...but this is what I have:
> 
> Active Problems:
> DM type II
> ...



Depending on your carrier, you may be able to use pertinent negative responses (ROS) as a HPI element.  

The CC is F/U of HTN and DM...it's possible to use chest pain as a HPI element (HTN) and polydipisia (DM) as a HPI element.  That leaves 3 more elements for your ROS.

*Can negative responses be included in the history of present illness (HPI) elements?*

Per WPS Medicare Part B, yes both pertinent positives and negatives may be included in the HPI. However, as a general rule, the HPI consists of subjective complaints that come voluntarily from the patient. Pertinent negative responses that are the result of questions posed to the patient by the physician usually fall under the Review of Systems. 

http://www.wisconsinmedicalsociety.org/education/faq#q15

*When scoring the review of systems (ROS), can you use the systems addressed in the history of present illness (HPI) elements or is that "double dipping"?*

ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered "double dipping" to use the system(s) addressed in the HPI for ROS credit.

https://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#18

*Can a physician count a single history item in both the HPI and ROS? For example, could we count "shortness of breath" as an associated sign and symptom in the HPI and respiratory system in the ROS? *

A 6. A clearly documented medical record would prevent the need to "double-dip" for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statement in both areas if necessary. 

So...if your carrier allows for this type of scoring and you're not double dipping...you can use HPI/ROS interchangeably.  Below is a great article also...

http://www.ercoder.com/discussion/topic.php?id=17


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## LindaEV (Nov 30, 2009)

Rebecca, this is great. Thanks again,,,you are wonderful!


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