# HPI documentation



## klgoulet1019@gmail.com (Nov 14, 2016)

I was wondering the opinion of others.  I work for Nephrologists who see patients for chronic kidney disease, HTN, diabetes, and any other associated issues that develop because of their chronic kidney disease.

I am doing internal audits and I am having a problem with documentations  of the HPI.  If the provider documents the condition of the 3 chronic illnesses in his assessment and plan, can I count this as part of the HPI?

Can I get some thoughts?
thank you!


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## kroemer4 (Mar 17, 2017)

It is appropriate to document the status of 3 chronic conditions for an extended HPI instead of listing 4+ individual HPI elements for one condition. This was historically acceptable with 1997 DGs, but now for services performed on or after September 10, 2013 for 1995 DGs. The definition of status in this instance does require some HPI elements and not just "Pt presents with hypertension, hyperlipidemia, and diabetes; here for follow-up. No changes."  CMS & auditors are looking for the HPI elements to exist, but shared among the chronic conditions. 

Nice article from the Medical Group Management Association. HPI is 3rd paragraph down from "Auditing Documentation to Support E&M Services" header: http://www.mgma.com/practice-resour...14/chart-auditing-for-compliance-and-training


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## marissa21p (Mar 21, 2017)

*3 Chronic Conditions in Kidney Failure*

This would apply for a Comprehensive HPI points with documentation and review of 3 chronic conditions per CMS 97 guidelines.
Marissa Padworny  CPC


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