Status of three chronic conditions

ccoonce

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Does the status of three chronic conditions have to appear in the HPI section or can it be taken from the Medical Decision portion? I have a supervisor that states we can take the status of three chronic conditions to count toward an Det. or Comp. HPI, is this appropriate?
If anyone has any references on this please let me know.

Thanks!
 

Lisa Bledsoe

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I don't have any documentation, but it does not seem logical to take something out of the MDM and apply it to the HPI. And you certainly can't use it in both areas if not documented in both.
 

codegirl0422

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It doesn't seem logical, but I have always been told to mentally erase the labels on the various sections of the note. HPI is HPI, . ROS is ROS. PFSH is PFSH. Exam is exam. With the exception of "associated signs and symptoms" (in the HPI) and ROS, regardless of where it's written. I do not have any documentation on it. If you use it, be careful not to double dip (use it in both areas). Also, remember to if you use the chronic conditions in HPI, you must follow 97 guidelines.
 

NishaJ

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HPI is a patient portion, whereas MDM is an assessment done by physician, and finally the provider has documented the conditions and its status. how we could consider this for HPI. Plz help me on this..

Thankzzz
 

Chelle-Lynn

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The requirement for the 3 chronic condition portion of the history is that the status of the chronic conditions comes from the patient.

Example:

Patient notes that their blood sugar at home has been approximately 120 for the past month. In addition they have noted that their HTN is
elevated. They also noted that their pain control in regards to their arthritis is within reasonable standards

If the status of the 3 conditions documentation in the MDM is noted as coming from the patient then it can be attributed to the History.
 

NishaJ

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thank u very much for your immediate reply chelle...
Incase, In HPI they have mentioned f\u DM, nothing else we have found in HPI . But in MDM portion, they have mentioned HTN-Stable, DM-controlled,
Hyperlipidemia- stable. can we consider this is for HPI.
 

Chelle-Lynn

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No, I would not consider this as part of the 3 chronic conditions as it does not state that the information came from the patient. It appears to be physicians summary of their conditions.

In the MDM Portion they have mentioned
* HTN - Stable
* DM - controlled
* Hyperlipidemia - stable
 

lisigirl

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I just wanted to add my two cents :) I agree with Chelle that the status of the 3 chronic conditions need to be from the patient so you would expect to see subjective statements. For example, HTN has been stable per home BP checks. no CP. Taking meds daily. etc.

However, IF a provider wrote all of that under the A/P, I would credit it to the HPI. It doesn't matter where in the note it is written as long as it is clear this was information collected from the patient.

Lisi
eharkler@nm.org
 
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