Wiki E&M with chronic and acute conditions

[Radcoder86]

I often get a little confused when trying to figure out what level to bill when a patient comes in for a f/u up on chronic conditions, but is also seen for an acute condition. If I mark status of 3 chronic conditions, how do I add in elements for the acute condition? Oftentimes the doctor's don't go into much detail on the chronic conditions, they just give a quick status update, so there aren't many HPI elements I can mark and feel like the level would go down if I had to only choose elements. How do most coders audit these types of visits? Thanks!

 

[jmconnor]

I often get a little confused when trying to figure out what level to bill when a patient comes in for a f/u up on chronic conditions, but is also seen for an acute condition. If I mark status of 3 chronic conditions, how do I add in elements for the acute condition? Oftentimes the doctor's don't go into much detail on the chronic conditions, they just give a quick status update, so there aren't many HPI elements I can mark and feel like the level would go down if I had to only choose elements. How do most coders audit these types of visits? Thanks!

When a provider is documenting his HPI, the status of the chronic conditions must be addressed, which it sounds like is already being done. Below that, the provider may document the details about the acute condition. When billing, as long as you have the status of the chronic conditions, that would help you meet your level on the HPI. Under the GL, as long as you have the status of 3 chronic conditions or 4 elements about the acute condition (location, severity, etc), then you would have a comprehensive HPI>