1. The status of at least three chronic or inactive conditions in the HPI:
If this is documented then the HPI automatically reaches the highest level possible for the HPI, referred to as “extended.” In some practice types it is difficult to reach an extended level using the HPI elements (duration, location, severity, quality, timing, associated signs and symptoms, context, and modifying factors). For example, when patients present for a return visit to monitor several chronic diseases and their symptoms are stable, the provider merely has to list three or more of their chronic conditions and comment on their status (e.g., “hypertension well controlled on current regimen, COPD stable with moderate SOB with exertion, hyperlipidemia but response to Lipitor suboptimal”).
Given the importance of the HPI level in determining the final E/M code this one item has the potential to markedly impact coding levels in certain practices. Confirmation with your carrier is recommended, but in 2013 CMS authorized the use of this feature of the 1997 E/M coding guidelines when providers are using the 1997 or 1995 examination guidelines. Don’t rely on your EHR vendor, as the vast majority of EHRs with automated coding tools do not have the ability to automatically recognize chronic conditions and their statuses within the HPI.
Clinical Example: A 10 provider cardiology practice was relying on the 8 HPI elements to determine the level of service for each established office visit. A high percentage of these visits contained 1-3 documented HPI elements (e.g., “infrequent chest pain with exertion”) but the focus of these visits was on managing 3 or more chronic conditions (e.g., hypertension, coronary artery disease, dysrhythmia, etc.). Educating the providers on when to override their EHR from a brief to extended HPI resulted in a significant increase in the accuracy of their coding and increases in revenue.
Disclaimer: The information represented in this article represents the opinions of Michael Stearns, MD, CPC, CFPC.
For additional information and assistance with interpreting and utilizing E/M coding guidelines, protecting your practice from negative audits, and responding to an audit, please contact Dr. Michael Stearns at email@example.com.