The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.
This article does not apply to services performed after 1-1-2023.
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.
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:
- “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.