Pulmonology Coding Alert

Question: The 1997 documentation guidelines state that I can achieve an extended history of present illness (HPI) by updating the status of at least three chronic or inactive conditions. Does this information have to be in the HPI section of the note, or may I pull the information from the assessment section of the note?


Colorado Subscriber

Answer: Depending on your contractor, you may be able to count the information in the assessment as a condition status update. 

Most contractors require that you obtain the HPI as a part of the historical information received by the patient, and may misinterpret the HPI information found in the assessment as a part of the physician's medical decision-making (MDM). However, remember that 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 front of the visit, although for audit purposes it may be helpful to reference them in the HPI section, too.

Using the HPI alternative in the 1997 guidelines may help you receive higher credit for your services when patients have chronic conditions, such as asthma or emphysema. 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.

Some contractors do not limit the use of the HPI alternative only with 1997 guidelines. Typically, the physician will use the 1995 HPI format for new patients and consults that present with acute issues or chronic conditions that the physician must review in detail. The 1997 HPI format is best used with follow-up patients who  do not have any acute problems. 

When the pulmonologist sees an established patient, you select your visit level based on two of the three key components; in these instances, you can use history (1997 format) and MDM, even if the exam was documented according to 1995 guidelines.