CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

  • Become a member
  • E/M Changes for 2021
  • Learn More
    • What is CodingIntel?
    • Membership pricing
    • Free resources
      • Can I Get Paid
      • Nicoletti Notes
      • Everyday Coding Q&A
      • Newsletter Archives
      • NEW! Site map
  • Member Resources
    • NEW! Site map
    • Home
    • Articles
    • Coding Guides
    • Quick Reference Sheets
    • Webinars
  • Coding Education
    • Webinars
    • Courses
    • Specialty resources
    • HCC Coding Guide
    • Order print resources
  • My Account
    • Login
    • Logout
    • Manage Account

Counting conditions in the HPI and assessment

Question:

This question pertains  to the 1995/1997 Guidelines, and not to the revised office/outpatient codes 99202–99215 in 2021.

When counting the chronic conditions for the history of the present illness (HPI) can the status of the condition be taken from the assessment and plan? If so, can it be counted for MDM as well as HPI? Or, would that be counting it twice.

Answer:

The status of the chronic diseases in the HPI refers to what the patient reports about their conditions. Are they having symptoms? What medications are they on? What does the patient say about managing their conditions at home?

Here’s an example of the status of one chronic illness in the HPI.

HPI: Diabetes with neuropathy:

“She reports her BS are under good control. She checks them daily and adjusts her insulin dose. Fair diet. She denies any polydipsia, polyuria.  No numbness, tingling or pain in extremities. Still taking the gabapentin. Her last HgbA1c was 8.2.”

The status of the patient’s chronic illness in the assessment is the physician’s evaluation of the patient’s condition.

Assessment and plan:

  1. “Diabetes with neuropathy. Fair control. I would like her to see the nutritionist for help with menus and meal planning. I am not adjusting her insulin dose now, but I would like to see her back in 3 months. Neuropathy symptoms well controlled on medication. Refills sent.”

They are two different components of the note. One describes how the patient is doing based on the patient’s report and the other is the physician’s assessment of the condition.

Neither counts for both the HPI and the assessment.

 

Back to Everyday Coding Q&A

 


Get more tips and coding insights from coding expert Betsy Nicoletti.

Subscribe and receive our FREE monthly newsletter and Everyday Coding Q&A.

Sign up

We will never share your email address. Unsubscribe anytime.

Last revised January 4, 2021 - Betsy Nicoletti
Tags: Documentation Guidelines

Looking for training on the new E/M Guidelines for 2021?

"Documentation Essentials for Codes 99202-99215 in 2021" is now available!

Take the two hour course on-demand, or sign up for one of our live events with Q&A.

Learn more

Latest Intel

How medical practice services are paid | Webinar

How medical practice services are paid May 20, … Read More...

Office Visit Fees in 2021

CMS released the updated conversion factor for … Read More...

CMS’s 2021 Physician Fee Schedule Final Rule | Webinar

2021 Medicare Physician Fee Schedule Final … Read More...

Physician Fee Schedule Final Rule for Calendar Year 2021

If you haven't signed up already, register for the … Read More...

Browse By Categories

Browse Content

  • Articles
  • Coding Guides
  • Everyday Coding Q&A
  • Videos
  • Can I Get Paid to
  • Blog
  • Webinars
  • Podcasts

Tags

behavioral health category of service CCM CMS Code sets and reimbursement Compliance compliance issues consults CPT®codes CPT® rules critical care Dermatology diagnosis coding Documentation Guidelines E/M other E/M services exam general surgery global surgery rules HCC HCPCS codes ICD-10 ICD-10-CM level of service MDM medical decision making Medicare Medicare rules modifiers new patient other E/M services Physician Billing physician coding preventive medicine preventive medicine services primary care procedure coding prolonged services psychiatry risk adjusted coding screening teaching physician rules telehealth using time to select a code Wellness Visits
  • About
  • FAQs
  • Terms of Use
  • Privacy Policy
  • Contact

Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

Copyright 2021, CodingIntel
Privacy Policy