Primary Care 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 SubscriberAnswer: 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 FP 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. [...]