# Hpi-patient his dictation



## NESmith (Jul 21, 2010)

I have a provider that when he sees a patient his dictation reads; Reason for visit-Follow-up of chronic medical problems and plan of care. review of test results. Chart reviewed. He then lists the patients chroninc problems and does no ROS. He states that this is all I need because he discusses the chronic medical problems in the assessment of plan. I disagree. Am I correct? Thanks for your help as always.


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## Jagadish (Jul 24, 2010)

We can credit this the HPI wherever it is documented. In this case, the status of the chronic conditions.


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## SCanterbury (Jul 27, 2010)

Sorry. You can't credit the simple listing of chronic conditions in the History as being HISTORY documentation of the current _status_ of the chronic conditions.

Realize that information regarding the status of chronic conditions is being used for patient HISTORY, so it is the PATIENT's impression and report of the status of their chronic conditions, as in "Well doctor, my arthritis has been acting up really bad with the pain a lot worse this past week. My blood pressure seems to be stable--no symptoms and the machine at the pharmacy two days ago said it was only a little high. My blood sugar..."

Sure--the doctor will provide his clinical impression at the end of the record in the assessment/plan as to what he feels the current status of the conditions are, but this is not HISTORY information, and should not be used to satisfy the "status of 3 + chronic conditions" HISTORY documentation requirement.

Seth Canterbury, CPC, ACS-EM


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## Jagadish (Jul 29, 2010)

HPI is the chronological description of the current problem. Generally, it is reported by the patient. But, in case of "interval history (99231-233)" and status of the conditions, there should be status of the condition documented, not necessarily always based on patient's words.


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## SCanterbury (Aug 4, 2010)

For the information regarding the status of chronic conditions to count as "history," though, it needs to be presented in the record as being just that--the understood/perceived status of the conditions *at the outset of the encounter* based on events/signs/symptoms _leading up to _today's encounter. 

The "status" of the conditions that is credited as "history" information is *not *the doctor's writing at the end of the visit after he has examined the patient and is giving his clinical impression. This final, end-of-encounter judgement regarding the status of chronic conditions is not "history."

I would be happy to view any documentation or cite that says that the "status" of chronic conditions that can count as an "extended" HPI can be based, not on the status as reported at the beginning encounter based on events leading up to the current visit, but can instead be based on the final assessment and plan of the provider, the formulation of which is a process dictinct from history-taking.

Seth Canterbury, CPC, ACS-EM


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## rthames052006 (Aug 5, 2010)

*Highmark Medicare*

This is what I pulled off www.highmarkmedicareservices.com- who is the local Medicare carrier in my area....

If you go to their site, pick Physician/Providers Part B at top middle of screen , then on the left handside you will see some categories go to the bottom of that list to "additional resources" then click reference library then frequently asked questions... this is listed as question #6 below...



6.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.

Date Posted: 10/05/2009, Date Reviewed/Revised: 05/26/2010


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## SCanterbury (Aug 10, 2010)

Highmark is entitled to their interpretation, but I don't agree with it.

Just remember that this is the carrier that says this on the same page:

Under the Examination Section of the 1995 Scoresheet, can we combine the body areas and organ systems?

No.  The examination section of the 1995 scoresheet is divided into body areas and organ systems. The Current Procedural Terminology (CPT) manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient's medical record you can use either the body areas or the organ systems.​
Does the body areas of the examination section of the 1995 score sheet work exactly as the organ systems?

You may count up to 7 body areas or 7 organ systems for an expanded problem focused or detailed examination, and you may count 8 body areas or 8 organ systems for a comprehensive examination. However, you may not add body areas and organ systems together to determine the level of the examination.​
The above answers are obviously incorrect. You can use both body areas and organ systems in all levels of the exam except for the comprehensive level. In the comprehensive level you cannot use either 8 systems or 8 body areas. It must be at least 8 systems, with any body areas examined being over and above the 8 systems.

The point is that specific carriers do comment on these issues, but in most cases they are throwing in their interpretation which is often as flawed as that of many coders. If there is a cite at the FEDERAL level (CMS manual or quote from a CMS rep), that will carry much more weight.


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## rthames052006 (Aug 11, 2010)

*Really!!!*



SCanterbury said:


> Highmark is entitled to their interpretation, but I don't agree with it.
> 
> Just remember that this is the carrier that says this on the same page:
> 
> ...



You are  very interesting... you specifically asked if it was documented somewhere about the chronic conditions ; so I copied and pasted the documentation from Highmark, now it's not a good enough source!  

I believe what the "original poster" should do is contact their local carrier to get guidance, thats what I would do in this case.


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## SCanterbury (Aug 16, 2010)

I should have specified that I'd like to see a cite or source from someone at the federal level/CMS, which would apply to everyone in the country. My apologies. Regional carrier statements do have value, but in the absence of federal language a regional interpretation only applies to those within that carrier's jurisdiction. Also, some carriers have a history of misinterpreting the rules, and their opinions carry less weight with me personally than others would.

So does anyone have a cite from someone at CMS?

I'd like to point out that the provision made in the '97 Guidelines was a re-worded version of the provision made in the '95 Guidelines. See the bolded words below:

1995: ﻿The medical record should describe *four or more elements of *[1] the present 	 
illness (HPI) or [2] *associated comorbidities*. _ "[1]" and "[2]" added by me._

1997: 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*.

The 1995 wording wasn't clear in that it didn't specify how many comorbidities needed to be commented upon in the history. To be safe, most consultants have operated under the impression that HPI-like detail should be taken for at least two comorbidities (since comorbidities is plural). For example, the patient could state that their diabetes has caused tingling/reduced sensation in a certain location. This reflects some detail regarding the condition, which is all that was required in 1995. Details that establish the recent status of the condition were not specified. Any details regarding the condition would suffice. 

In 1997, they clarified that the number of conditions commented upon should be 3, and that the detail obtained from the patient should be such that the condition's recent status can be established. This could mean that more than one HPI-like detail needs to be recorded. For example, the severity of the condition has been constant but the symtoms have increased in frequency (timing). These aren't just any details. They are more significant in that together they could establish the recent status of the condition. 

Though the '95 allowance regarding an alternative way to achieve an "extended" HPI is less clear in some ways than the revised allowance appearing in the '97 Guidelines, it does more clearly reflect that the information pertains to the status of the conditions up to the beginning of the current encounter and documented in the History portion of the note--not the "status" of the conditions as determined at the end of the encounter and documented in the Assessment/Plan portion of the note.


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