tci Part B Insider - 2007 Issue 37

Part B Coding Coach: The Experts Weigh In On Chronic Conditions And E/M Levels

Hint: Simply mentioning inactive conditions could lead you down the wrong pathThe 1997 documentation guidelines state that if your physician can update the status of at least three chronic or inactive conditions, the documentation would meet the criteria for an extended -history of present illness- (HPI). Get up to speed on how your provider should document these cases--and how you should code them. Watch Where The Documentation Is Although some physicians reference the patient's chronic conditions in the assessment section of the medical decision-making (MDM) section, some physicians choose to also discuss the chronic diseases in the HPI section...

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