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 Subscriber

Answer: You can count the information in the assessment as a condition status update. The family 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 1997 guidelines may help you report higher-level services for patients who have chronic conditions, such as hypertension and diabetes. 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. Therefore, the 1997 guidelines may allow you to code a higher-level E/M code for encounters that involve periodic prescription renewals without the family physician's having to go into as much detail.

Example: A Medicare patient who has controlled benign hypertension (401.1, Essential hypertension; benign), controlled type II diabetes (250.00, Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) and severe allergies (477.x, Allergic rhinitis) presents for a follow-up of his hypertension and diabetes. After an appropriate exam, the FP renews the patient's prescription and notes:

- hypertension--active, stable

- diabetes--active, stable

- hay fever (477.9, ... cause unspecified)--active, stable.

Because the physician indicates the status of at least three chronic or inactive conditions- status, using the 1997 guidelines you may report an extended HPI. When combined with an appropriate review of systems and past, family, and social history, the extended HPI may result in a detailed history. If the FP performs either a detailed examination or moderate-complexity medical decision-making, you may report the encounter with 99214. Remember: Medical necessity should ultimately drive the visit's history and examination.