Internal Medicine Coding Alert

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?


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Answer: You can count the information in the assessment as a condition status update. The physician 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 top of the note, although for audit purposes it may be helpful to reference them in the HPI section, too. However, it is important that it be clearly identifiable that the chronic conditions are updated.

Keep in mind that the physician must mention the status of the condition, such as “Hypertension, stable. Continue medications as prescribed,” rather than just listing the condition on the assessment.

Using the 1997 guidelines may help you report higher-level services for patients who have chronic conditions, such as hypertension and diabetes, that affect treatment plans. 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 code a higher-level E/M code for encounters that involve periodic prescription renewals without the physician having to go into as much detail.

Keep in mind that you cannot mix components of the 1995 and 1997 guidelines -- you must pick one and stick to it throughout the chart.

Remember: Medical necessity must ultimately drive the visit’s history and examination levels.

Answers to You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, director of government program services for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for achlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.