HPI documentation

Messages
3
Best answers
0
I was wondering the opinion of others. I work for Nephrologists who see patients for chronic kidney disease, HTN, diabetes, and any other associated issues that develop because of their chronic kidney disease.

I am doing internal audits and I am having a problem with documentations of the HPI. If the provider documents the condition of the 3 chronic illnesses in his assessment and plan, can I count this as part of the HPI?

Can I get some thoughts?
thank you!
 

kroemer4

Networker
Local Chapter Officer
Messages
45
Location
Davenport, Iowa
Best answers
0
It is appropriate to document the status of 3 chronic conditions for an extended HPI instead of listing 4+ individual HPI elements for one condition. This was historically acceptable with 1997 DGs, but now for services performed on or after September 10, 2013 for 1995 DGs. The definition of status in this instance does require some HPI elements and not just "Pt presents with hypertension, hyperlipidemia, and diabetes; here for follow-up. No changes." CMS & auditors are looking for the HPI elements to exist, but shared among the chronic conditions.

Nice article from the Medical Group Management Association. HPI is 3rd paragraph down from "Auditing Documentation to Support E&M Services" header: http://www.mgma.com/practice-resour...14/chart-auditing-for-compliance-and-training
 

marissa21p

Contributor
Messages
19
Best answers
0
3 Chronic Conditions in Kidney Failure

This would apply for a Comprehensive HPI points with documentation and review of 3 chronic conditions per CMS 97 guidelines.
Marissa Padworny CPC
 
Top