1997 E/M GUDIELINES DOCUMENTING 3 CHRONIC CONDITIONS TO COMPLETE AN EXTENDED HPI

aparscal

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PER THE 1997 GUIDELINES TO GET AN EXTENDED HPI THE NOTE HAS TO HAVE AT LEAST 4 ELEMENTS OF HPI, OR LIST 3 OR MORE CHRONIC CONDITIONS. IF I HAVE A NOTE AND THE PROVIDER LISTS 3 CHRONIC CONDITIONS DOES THIS COVER THE ENTIRE ASPECTS OF HPI? MEANING DOES 3 OR MORE CHRONIC CONDITONS WRAP UP THE ENTIRE HPI,ROS AND PFSH? FOR INSTANCE IF I AM TRYING TO BILL A 99214, DOES THIS AUTOMATICALLY INCLUDE AN EXTENDED ROS AND 1 PERTINENT PFSH?
 

thomas7331

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The HPI is not the same thing as the history, which consists of HPI, ROS and PFSH.

The listing of 3 chronic conditions is an alternate way of meeting the requirements for an extended HPI. It does not replace the ROS or PFSH which still have to be used to determine the level of the history:

"An extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions."
 

twizzle

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To be able to use the 3 chronic conditions it is insufficient to just document them. The provider has to document the status of those conditions.
Type 2 DM stable on Metformin.
Hypertension well-controlled on Lisinopril.
Hyperlipidemia worsening on current regimen of Simvastatin.
 

twizzle

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Please ignore my response above. It is not as I intended because it reads like an A/P.

Patient reports BP readings have been good on current meds.
Type 2 DM; blood sugars have been running a little high for past 3 months on Metformin.
Patient reports no episodes of shortness of breath and is able to exercise without complaints after their stent placement 6 months ago following an MI.

This is the type of information needed in an HPI for status of 3 chronic conditions.
 
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