Primary Care Coding Alert

Question: The history of present illness (HPI) section of the 1997 guidelines states that physicians can reach an extended history by -reporting on or updating three or more chronic or inactive conditions.- Would you clarify -chronic and inactive conditions-?
 
For instance, when a patient presents with symptoms of a urinary tract infection, the UTI would be a condition. But suppose the family physician later sees the patient for an upper respiratory infection, and the UTI is now resolved. In this case, would the UTI count as an -inactive condition-? Does the term -condition- imply something that is not an acute illness, such as diabetes, chronic obstructive pulmonary disease (COPD), hypertension, etc., which could all be chronic or in an inactive state?

California Subscriber
 
Answer: The phrase -chronic and inactive conditions- generally means something other than an acute illness (e.g, diabetes, COPD, hypertension, etc.), as you suggest. Under the 1995 documentation guidelines, when HPI was defined solely by such things as quality, location, severity, etc. (which are generally applicable to acute problems), there was no good way to classify the HPI of visits when the presenting problems were chronic, which is a common situation for family physicians. So, the 1997 guidelines added the -chronic or inactive conditions- caveat to fill the void.
 
That being said, any illness or problem is a condition.
 
In your example, when the visit for the URI (such as 465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site) is the first visit after the UTI (e.g., 599.0, Urinary tract infection, site not specified), you can count the condition if the FP follows up on the condition by asking about it and documenting the discussion in the HPI. He shouldn-t, however, ask about the UTI condition at every visit and expect to count it.
 
Common-sense approach: If a medical reason exists to ask about the condition and document it, you should count the condition toward the HPI. Asking about a gall bladder that was taken out two years ago makes no sense, but asking about serious depression (for instance 296.2x, Major depressive disorder, single episode) that is six months old is appropriate.