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Crediting 3 Chronic Conditions

  1. #1
    North Carolina
    Question Crediting 3 Chronic Conditions
    Medical Coding Books
    I'm curious what your view is on this...

    I know that you can achieve an extended HPI if the provider documents the status of as least three chronic or inactive conditions. Here's my question. Let's say, for instance, the physician is somewhat vague in the HPI section. However, at his assessment plan, the provider documents detailed information about the chronic conditions, the medication(s) and their status'. Would you credit the physician since it's not in the HPI section but he does document it nicely at the end of the note. (Looking for your input Tessa.....)

  2. #2
    Milwaukee WI
    Default VERRRRY Interesting ...
    My first reaction is No ... because the status of chronic conditions in the assessment/plan would be part of the MDM (no double dipping).

    But then ... if you absolutely don't need the statement for any part of MDM ... I suppose you could count it towards HPI.

    I have seen notes that are all just one long paragraph with no neatly identified subheadings to tell me where to count something. I get out my set of colored highlighters ... pink for HPI, green for ROS, yellow for PMFSH, purple for exam, and blue for MDM. The colors of highlight can be (and frequently are) mixed up on the page, as long as I'm not double dipping, I feel okay about the level of service.

    Just thinking out loud here ... Does that help?

    F Tessa Bartels, CPC, CEMC

  3. #3
    North Carolina
    Yes...It does. Honestly, I had never thought of this until another coder mentioned this to me. I've chewed on this for awhile and just couldn't make a decision. I know others may frown on it but, with your explanation, I could see it working. I really appreciate your input. Although I'm working very hard at it and plan on testing for the E/M exam, I'm not as seasoned as you.

    Thanks again~

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