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Cindy Posted Wed 03rd of January, 2018 07:29:49 AM
I have a question on the level of visit. I have a physician you consistently uses the following note in her HPI, Patient here for lab reviews and chronic conditions of, hypertension, diabetes, hyperlipidemia, hypothyroidism. This is just a sample of different diagnosis, the patient's usually have 3-6 chronic conditions. Nothing else in the HPI other than, patient feeling well. This physician has her patients come back every 3 months. She goes on to do a sometimes a detailed exam, sometimes a expanded problem focused. The treatment plan is usually stay on current meds, or sometimes renew meds. Here is my question, she insists on billing a 99214 all times. Under the treatment plan she will state all chronic conditions are stable, or if there is problem then she notes this. I have told her she needs to put this information in her HPI to achieve the level of 99214, can she count the status of 3 or more chronic conditions if they are addressed in the treatment plan and not in the HPI? 99214 states detailed HPI, based on her notes it seems it is a problem focused. Any help would be appreciated as this is causing some coding problems. Thank you
SuperCoder Answered Thu 04th of January, 2018 04:25:52 AM

For established patient, it required: at least 2 of these 3 key components–

·         Detailed History (HPI, ROS, PFSH)

·         Detailed Examination

·         Medical Decision Making (MDM) of moderate complexity

In HPI, Status of 3 or more chronic conditions makes the HPI level as Problem focused (PF), to lift the level of History; ROS and PFSH also play a role.

If you have Status of 3 or more chronic conditions under HPI, then assess ROS (minimum 2 elements of different system like, Cardio, Endo, Respi, etc) and PFSH (minimum 1 element like, family, social or medical history) to make the History level as Detailed. If history is not detailed, then try to maintain the Examination and MDM as Detailed and Moderate respectively for the 99214 level.

About the chronic conditions, it should be clearly mentioned under HPI section also, it cannot be calculated under HPI when mentioned in MDM section. 

Cindy Posted Thu 04th of January, 2018 08:14:15 AM
Thank you. To be clear I cannot count the status of Chronic Conditions in the HPI because she only states her for follow up of chronic conditions, but does not mention any status in the HPI. Nothing else is mentioned under than here for review of labs and follow up of chronic conditions. We have had a long running difference of opinions on this. So basically the HPI is brief, correct? Then I go on to count ROS and PFSH.
SuperCoder Answered Fri 05th of January, 2018 02:28:50 AM

Chronic conditions can be counted in HPI, when it is mentioned in the HPI section, it cannot be pulled from MDM. Moreover, chronic conditions can be mentioned in HPI and MDM as well, so coder can count it for both; HPI and MDM. On the other hand, if HPI is not at physician’s desirable level, then focus on the ROS and PFSH to up lift the care of patient and level of billing.

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