Gastroenterology Coding Alert

Question: When counting E/M history, can we use chronic medical conditions in place of elements to qualify for the history of present (HPI) illness tally?

Connecticut Subscriber

Answer: This is where the 1995 and 1997 guidelines get muddied. If you are using the 1995 guidelines, counting the HPI based on the number of chronic conditions is not acceptable. Under 1997 guidelines, however, you can use the status of one to two chronic medical problems instead of one to three HPI elements, and status of three chronic medical problems instead of four or more HPI elements. But whichever set of guidelines you use, make sure you use one or the other, not both, except for the specific instance of using the status of “three or more chronic conditions (1997) in a note that otherwise follows 1995 guidelines for the details of a physical exam.”

As CMS states in its MLN document Evaluation and Management Services, “For reporting services furnished on and after September 10, 2013, to Medicare, you may use the 1997 documentation guidelines for an extended HPI along with other elements from the 1995 documen­tation guidelines to document an E/M service.”

The golden rule: Your provider must obtain this portion of the history. In many offices, the clinical staff will list the chief complaint and maybe even a couple of statements. However, the provider will need to perform and document the HPI portion of the service for it to count in an audit.