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?

Colorado Subscriber

Answer: Some payers consider the information in the assessment as a condition status update. Others believe it is not attributable because this is the physician's determination of the patient's current conditions based on the current assessment.

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.

Important: Documentation should clearly indicate the chronic conditions that are updated. The physician must mention the status of the condition, such as "Asthma, stable (such as 493.01, Extrinsic asthma; with status asthmaticus). Continue medications as prescribed." Simply listing the condition on the assessment is insufficient documentation for an update.

Tip: Using the 1997 guidelines may help you report higherlevel services for patients with chronic conditions, such as COPD (496, Chronic obstructive pulmonary disease, not elsewhere classified) and hypertension (401.1, Essential hypertension; benign), 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. But remember that medical necessity must ultimately drive the visit's history and examination levels.

Some Medicare Part B carriers allow you to apply the chroniccondition alternative with the 1995 guidelines. Check with your carrier for further guidance.