Ophthalmology and Optometry 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: A physician can obtain an extended history of present illness by reporting the status of three chronic or inactive conditions. Keep in mind that the history component also includes the review of systems (ROS) and when applicable to the E/M code, the past, family and social history (PFSH). Don't base the determination of the overall history level on the HPI alone. It is practical for a physician to obtain this information in the subjective findings of the patient encounter. This allows the physician to determine whether current or prior chronic conditions will require a more extensive exam or play a role in the workup, treatment and medical decision-making. Although the physician may organize the documentation of this information in any manner he chooses, it does make more sense to see this documentation in the subjective findings. If a specific chronic or inactive condition plays a role in the physician's medical decision-making, he should list it as a secondary diagnosis as the physician's assessment, impression or findings. Keep in mind that the physician must state the status of the condition, such as "Hypertension, stable -- controlled with medications," rather than just listing the condition. Also keep in mind that you cannot mix components of the 1995 and 1997 guidelines -- you must pick one and stick to it throughout the documentation of the specific date of service. Remember: Medical necessity must ultimately support the overall level of history and examination. Recently some carriers have also included the policy of reporting the presence and status of three chronic conditions as part of the HPI for the 1995 guidelines. As always, check with the specific carrier for details of this possible update in writing from your local carrier.