Medicare Compliance & Reimbursement

Hint: Simply mentioning inactive conditions could lead you down the wrong path The 1997 documentation guidelines state that if your physician can update the status of at least three chronic or inactive conditions, the documentation would meet the criteria for an extended "history of present illness" (HPI). Get up to speed on how your provider should document these cases -- and how you should code them. Although some physicians reference the patient's chronic conditions in the assessment section of the medical decision-making (MDM) section, some physicians choose also to discuss the chronic diseases in the HPI section of notes. But is this the best tactic for your group? The short answer: Many coding consultants discourage physicians from documenting the illnesses in two separate sections unless you specifically address that issue during the visit. Example: "Very few pain management doctors document the status of chronic conditions outside the diagnoses they are treating," says Marvel J. Hammer, owner of MJH Consulting in Denver. Even if your physician includes the patient's current conditions in the assessment portion of his documentation, he might not include comorbidities that can impact care. "An auditor should not give credit in both key components unless the chronic conditions are specifically addressed in both areas and meet medical necessity for their inclusion," Hammer adds. If your physician does address the chronic condition during the visit, be sure he has distinct documentation for HPI and MDM. Example: The physician typically documents the history in the first part of the visit note following the patient's chief complaint or presenting problem. The history helps the physician determine which aspects of the physical exam are complete, so he can continue the patient assessment and care plan. Documenting these steps helps justify the physician's medical decision-making. Coding for E/M services can be confusing because of having two sets of accepted guidelines you can follow. Because of this, be sure you know the differences between the 1995 and 1997 versions before determining your best coding route. 1997 advantages: Using the 1997 guidelines may help you report higher-level services for patients who have chronic conditions, such as postlaminectomy syndrome (722.8x), rheumatoid arthritis (714.x, Rheumatoid arthritis and other inflammatory polyarthropathies), complex regional pain syndrome (CRPS) (337.2x, Reflex sympathetic dystrophy; 354.4, Causalgia of upper limb; or 355.71, Causalgia of lower limb) or fibromyalgia (729.1, Myalgia and myositis, unspecified). Unlike the 1995 version, the 1997 history elements allow a provider to meet an extended level of HPI by meeting either the requirements of the four elements of HPI or the status of three or more chronic conditions. Therefore, the 1997 guidelines may allow you to report a higher-level E/M code for encounters that involve periodic prescription renewals without the [...]