With the new Medicare policy, you can mix 1995 with 1997 to get the best HPI and exam for your clinical circumstance in order to determine the highest code level. Take a look at this clinical situation and the possible coding options.
Example: An existing 52-year-old male patient comes to see your physician. Your provider documents a chief complaint, more than 10 systems reviewed in review of systems, and complete past medical, family, and social history. For HPI he writes the following: “Patient’s hypertension is stable. He takes his blood pressure at home and I have reviewed his numbers for the last 30 days. Patient’s blood sugar readings for the past 30 days also look good. Diabetes appears stable. Patient’s labs show that his cholesterol is still running high despite medication. Wants change in medication as Lipitor isn’t covered by his insurance.” For the exam, your physician documents the patient’s vital signs and also writes: “Patient is oriented times three, looks well. Lungs sound clear. Heart sounds normal. Eyes PERRLA. Oropharynx WNL. Abdomen soft, non-tender. No edema. No rashes; skin clear.” The provider then documents moderate complexity MDM due to review of multiple chronic conditions, various tests being reviewed and ordered, and medication adjustments that raise the risk to moderate.
Start counting: When using 1995 HPI guidelines, you get brief HPI due to only three elements — location, severity, and modifying factors. Under 1995 guidelines, you can count a comprehensive exam because the provider documented examination of eight systems.
Under 1997 guidelines, you can count an extended HPI because the provider gives the status of three chronic conditions. For the exam, however, you will only get an expanded problem-focused exam under 1997 guidelines because the provider only mentions nine bullets from the general multi-system specialty exam guidelines.
If you use the 1995 HPI and exam, your code level will be 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity …) due to expanded problem focused history, comprehensive exam, and moderate MDM. With 1997 HPI and exam, you get 99214 as well due to comprehensive history, expanded problem focused exam, and moderate MDM.
New way: Now that you can mix and match the guidelines, your best bet for this encounter would be to combine the higher 1997 HPI to the other complete components of the history and the higher 1995 exam guidelines. That gives you comprehensive history, comprehensive exam, and moderate complexity MDM. This technically supports a 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity …).
Important: Be cautious, however, and be sure the medical necessity warrants 99215. The overriding criterion for coding an encounter is medical necessity and in the example, the need for the complete history and comprehensive exam is illustrated by the chronic illnesses. The 99215 is thus the billable level of service for this scenario.
