Status of 3 Chronic Medical Conditions For HPI and Medical Decision Making.

A reader recently requested more information on the evaluation and management rules for  using the status of 3 chronic medical conditions to substitute for the HPI as well as to be used in the  diagnosis component of medical decision making for a level three hospital follow-up note:
Thank you for your excellent examples on 99233 coding.  I believe many of us are under coding as well and would benefit from studying your examples closely. I do have one question for your however... In the following example you gave:
S) no CP, no SOB (2 ROS)
O) Nothing needed
A) 1) DM-stable
2) HTN-stable
3) chronic afib-stable
4) hypoxemia-new
P) Discussed code status today. Patient wishes to be a DNR due to poor prognosis. Check CXR
If the 4th diagnosis was another chronic stable problem such as CAD or CKD, can you use the status of the 3 chronic problems for your detailed History component (along with 2 ROS) AND can you use the same 4 chronic stable problems to achieve 4 points in the diagnosis section. So, that along with the decision to make DNR, it would qualify for 99233?
Thanks for your question.  Please reference the AMA's CPT 2014 Standard Edition as the definitive authority on CPT® descriptions.   However, I believe the answer to your question is yes.   This is often how I provide care that meets criteria for a 99233 hospital follow up note. There is nothing about "the rules" on how to write a progress note, for the purposes of billing CMS, that says the note must be in the S.O.A.P. format. That is how we do it because that is how we were taught as medical students to write our notes.

Try and find any rule that says CMS mandates S.O.A.P. notes to get paid and I'm certain you will not find any.  The fact that you define the status of your three chronic medical conditions in the assessment section only one time certainly qualifies for both the HPI chronic medical conditions substitution rule as well as the diagnosis componenent of medical decision making.  

I could very well have written my fully qualified 99233 note in essay form as follows:
Mr Smith has no cardiac or pulmonary complaints.  Although he is hypoxemic, (new from yesterday), his DM, HTN and chronic AF are all stable and I plan no changes in their management.  After discussing his change in condition, Mr Smith requests to be DNR.  CXR ordered.  See orders for details.
This note would also qualify for a level 3 hospital follow up (as per the reader's original question).  Here are 42 carefully placed words.
Mr Smith has no cardiac or pulmonary complaints.  His DM, HTN, chronic AFib and CAD are all stable and I plan no changes in their management.  We discussed resuscitation parameters due to his poor prognosis . He wishes to be DNR.  Order written.  
These two essays are fully qualified level three hospital follow up visits.  Shocking, isn't it?  You see, you don't have to write an entire page to get paid for the work provided.  Many doctors document based on the belief that if they write a lot or a little than they document a higher or lower code.  That is never how billing should be done. That's why Medicare fraud statistics are so out of touch with reality.

You just have to know what to document for the work provided.  This is why I always carry around my E/M reference cards with me on rounds and check them multiple times a day. The rules are so complicated, after an entire decade of hospitalist care, I still cannot remember all the criteria, points, etc of the Marshfield Audit tool that many Medicare carriers accept as appropriate documentation for evaluation and management codes.

UPDATE January 2014 from Today's Hospitalist. According to this linked article, practitioners can now use 1997 guidelines to bill for a complete HPI by documenting the status of three chronic medical conditions.  Prior to September 10th, 2013, this was only allowed by using the 1995 E/M guidelines.   Both the 1995 and 1997 guidelines can be accessed through my hospitalist resource section. 


LINK TO E/M POCKET REFERENCE POST


EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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