Strange...I had a question on this very subject the other day. I've always felt the 3 chronic conditions had to be documented in the HPI but there was a difference of opinion...however; the consensus was NO...you can not allow credit if it is only documented in the assessment. I really liked one of the responses I received...I'll share...
"If you interpret “status” in “status of at least three chronic or inactive conditions” to mean the ultimate “status” of a problem from a clinical standpoint as determined by the physician by the end of the encounter, which some do, then documentation as to the physician’s judgment regarding the current clinical status would reasonably be found in the assessment area of the note—not in the history. This view, however, is not consistent with the credit being given with the History component.
I prescribe to the view that the “status” referred to in that phrase must refer to information obtained from the patient during the history-taking, since it is credited that way. Since a patient is not qualified from a medical standpoint to explain to the doctor the ultimate/current clinical status for chronic problems they are experiencing, the “status” would refer to the patient’s non-medical subjective perception as to the current status of chronic problems they currently have, and then likely be accompanied by explanations for their perceptions and any actions/events that have occurred that have a bearing on the problem(s). For example, it would be the patient’s answer to a doctor asking the patient their general impression about any perceived improvement/worsening with regards to a chronic condition. If the patient feels that their hypertension is worse, the doctor will likely ask the patient to explain this perception. Why do they feel it is worse? Higher BP readings at the neighborhood drug store? Worsening of certain symptoms that accompany the htn? Have they stopped exercising? The patient may provide information about the status of key “associated signs/symptoms” that accompany each of the chronic conditions. All of this history information contributes towards describing the current subjective status of the problem as experienced by the patient. The physician will then determine the ultimate clinical status based on objective data obtained during the exam and MDM components."
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join