Question: The 1997 audit guidelines state that I can reach an extended history by updating the status of at least three chronic or inactive conditions. Does this information have to be in the history of present illness (HPI) section of the note, or may I pull the information from the assessment section of the note?
Colorado Subscriber
Answer: You can count the information in the assessment as a condition status update. The allergist may organize the notes in any manner he finds practical. For instance, he may update the illness(es) in the assessment section rather than in the HPI at the front of the visit, although for audit purposes it may be helpful to reference them in the HPI section, too.
Using the 1997 guidelines may help you report higher-level services for patients who have chronic conditions, such as rhinitis and sinusitis. Unlike the 1995 version, the 1997 history elements don’t require the four elements of HPI for an extended level of HPI because you can use the status of three or more chronic conditions. Therefore, the 1997 guidelines may allow you to report a higher-level E/M code for encounters that involve periodic prescription renewals without the allergist having to go into as much detail.
Example: A patient who has controlled asthma (493.01, Extrinsic asthma; with status asthmaticus), controlled pollinosis (477.0, Allergic rhinitis; due to pollen), and chronic frontal sinusitis (473.1, Chronic sinusitis; frontal) presents for a follow-up of his rhinitis and asthma.
After an appropriate exam, the allergist renews the patient’s prescription and notes:
• asthma--active, stable
• sinusitis--active, stable
• pollinosis--active, stable.
Because the physician indicates the status of at least three chronic or inactive conditions, using the 1997 guidelines you may report an extended HPI. When combined with an appropriate review of systems and past, family, and social history, the extended HPI may result in a detailed history.
If the allergist performs either a detailed examination or moderate-complexity medical decision-making, you may report the encounter with 99214 (Office or other outpatient visit for the evaluation and management of an established patient …). Remember: Medical necessity should ultimately drive the visit’s history and examination.
Answers to You Be the Coder and Reader Questions were answered/reviewed by Jim Collins, CPC, CHCC, president of Compliant MD Inc.; Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.; Bruce Rappoport, MD, CPC, a consultant with Rachlin, Cohen & Holtz LLP in Fort Lauderdale, Fla.; and Richard H. Tuck, MD, FAAP, at PrimeCare of Southeastern Ohio.
