EM Coding Alert

Remember the exam is the last criterion that differs from 1995 to 1997 guidelines.

CMS and the Department of Health & Human Services (HHS) have some good news for your practice when it comes to using a patient’s history of present illness (HPI), review of systems, and past, family, and social histories to choose the detail of the history component of the evaluation and management services. 

As of September 10, 2013, you can use the HPI criteria from either the 1995 or the 1997 Documentation Guidelines for Evaluation & Management Services. This allows the ability to now “mix” the best history with the best exam to determine the level of service, and will give your provider more options for meeting the level of service. 

Here’s a look at the change and how you can use this change to your benefit.

Refresh Your 95 vs. 97 HPI Knowledge

The HPI describes the development of a patient’s present illness from the first sign and/or symptom or from the previous encounter to the present encounter. 

1995 way: Under the 1995 guidelines, to assess the level of HPI, you count the number of HPI elements the provider reviewed and documented. The guidelines include eight elements:

• location
• quality
• severity
• duration
• timing
• context
• modifying factors
• associated signs and symptoms. 

The medical record should describe one to three elements for a brief HPI. For an extended HPI, the medical record should describe four or more elements or associated comorbidities. You can count comorbidities in past history, ROS, or HPI.

1997 way: With 1997 guidelines, you choose a level of HPI based on the number HPI elements or the number of chronic or inactive conditions your provider reviews with the patient. A brief HPI consists of one to three elements. An extended HPI consists of at least four elements or the status of at least three chronic or inactive conditions.

Get to Know the Change

Thanks to the new guidance from CMS and HHS, you can now mix and match the 1995 and 1997 ways of counting HPI with the exam and MDM.

“Beginning for services performed on or after September 10, 2013 you are able to  use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service,” announced CMS and HHS.

In other words: For services your physician has performed since September 10, 2013, you may use the 1997 documentation guidelines for HPI along with the exam criteria from the 1995 guidelines, or vice versa, using the 1995 HPI criteria with the 1997 exam guidelines.

In the past, you had to pick 1995 or 1997 guidelines and apply your choice to the entire encounter. But now, you can use either the chronic conditions or the HPI elements for history and still choose either 1995 or 1997 guidelines for the exam portion of the encounter. 

This change may make your job easier when you are reviewing your provider’s documentation and determining the best code to assign. “I find it beneficial in that providers may have been trained to document using either of the documentation guidelines,” Lynn M. Anderanin, CPC,CPC-I, COSC, ICD10, is the sr. director of Coding Compliance and Education for Healthcare Information Services in Park Ridge Ill. “When auditing records, I can usually recognize which they are using. This allows me to able to use either/or to justify the level of service.  Often, the 1995 guidelines for examination are easier to obtain than the 1997 guidelines, especially in the higher levels of service.”

“If the physician is a specialist, there might be times that the examination is targeted to the specific organ system, but there may be other times when a more general exam is warranted,” explains Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn. “Even in family practice or internal medicine, there might be times where examining one organ system thoroughly might be required for the problem/patient, but then other times where a more thorough general examination is needed. Having the flexibility assures that you will get paid appropriately for the services you render (and document appropriately).”

Pointer: Medicare contractors such as First Coast Service Options, Inc. (medicare.fcso.com/faqs/answers/197576.asp) and Noridian Healthcare Services (med.noridianmedicare.com/web/jeb/specialties/em) have announced they will recognize either the 1995 or 1997 guidelines for the HPI no matter which guidelines were used for the exam. Make sure you check with your payers to see if they will recognize this guidance or not.