Only 1 or 2 Chronic Conditions

anne32

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I understand that under 97 Guidelines, we can count an extended history if the status of 3 chronic or inactive conditions are being addressed. My question is, what if the patient only comes in for 1 or 2 chronic or inactive conditions? How do you calculate the hx and total E/M?
 

mhstrauss

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I understand that under 97 Guidelines, we can count an extended history if the status of 3 chronic or inactive conditions are being addressed. My question is, what if the patient only comes in for 1 or 2 chronic or inactive conditions? How do you calculate the hx and total E/M?

The audit tool I have (from my MAC Novitas) shows 1-2 chronic conditions to fall under Expanded Problem-Focused HPI. The overall hx and total E/M would depend on all other elements documented.
 

anne32

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So using chronic conditions to calculate the HPI can only be used in the 97 Guidelines, but the exam has to be identified by bullets, correct? And there are specific requirements about what is considered enough documentation to count a body area or organ right? Does anyone have more info on this?
 

jsalzer50

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E/M coding

Hey Anne,

I'm only coding student. Nevertheless, I will do my very best to help. Here is my understanding:

The Body Areas (BA) are more specific and are as follows:

1. Head (including face)
2. Neck
3. Chest (including breasts and axillae)
4. Abdomen
5. Genitalia, groin, buttocks
6. Back (including spine)
7. Each extremity (up to 4)

If there is any documentation about the physician/healthcare professional touching, observing, or listening to any of these body areas, we account for that under the exam.

For the exam, we combine the BA/OS total number to see if it falls under:

Problem-Focused: # of BA/OS = 1
Expanded Problem-Focused: # of BA/OS = 2-4 (limited)
Detailed: # of BA/OS = 2-7 (extended)

BUT, when we get to Comprehensive Exam, we only go by OS (organ systems) and don't account for any of the BAs. Comprehensive: # of OS = 8 or more.

There are times when I read: "Abdomen soft and tender, normal bowel sounds". With that sentence, I would actually check the box for Abdomen and check the box for Gastrointestinal because of the "normal bowel sounds", which goes beyond merely examining the abdomen.

Ideally, for the Physical Examination, the report is organized by body area and organ system. This of course makes a big difference for coders. But, some reports are not organized like this, as you probably already know. Then we have to dig deeper into the report.

I think E/M is probably one of the most challenging parts of coding. I find gray areas sometimes where a statement could fall under 1 or 2 organ systems and/or a BA. Here is one I thought about: "Patient has a severe, painful rash on his right arm." The severe pain part would go under ROS. But the rash would go under Integumentary (skin) for the OS under Exam. Then, I would also check the box for an extremity for the BA due to the specificity of right arm. I think this is reasonable because the doctor examined the extremity (R arm), and also the skin, so my understanding is we would account for both.

I've been studying E/M coding for the ER. I find the process of selecting those codes are much different than other E/M coding. I'd be happy to provide articles/resources about ER E/M coding if you'd like.

Hope this helps!

Sincerely,
Jacob
 
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