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94/95 Documentation Guidelines - HPI
By Shirley Moy - Posted on 11 November 2009
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We have noted that consultants and trainers are referring to the following documentation on the Medicare website as to whether 'chronic or inactive conditions' can be used to determine the level of the History of Present Illness when using the 94/95 Documentation Guidelines, as well as the '97 Documentation Guidelines.
As described in the Medicare Physician Guide (CMS-2007) the general guidelines for determining HPI levels are as follows:
History of present illness (HPI)-
Brief, which includes 1 to 3 elements
Extended, which includes at least 4 elements OR the status of at least 3 chronic or inactive conditions
According to Highmark Medicare Services, the 1997 guidelines provided "the specialty examination guidelines only. Therefore, the history and medical-decision making
components from the 1995 guidelines are used for all evaluation and management services. This said, under the history
component, the Status of chronic conditions was added after the 1995 guidelines were instituted. This element of the
history component is also available for all services."
In addition, Highmark submits the following clarification:
"According to the Evaluation and Management (E/M) Guidelines, the History of Present
Illness (HPI) portion of the History component may be substantiated by documenting
either the status of chronic conditions or the HPI elements. The guidelines are clear that
in order to receive a brief HPI, a provider must document one to three elements of the
HPI or one to two chronic conditions. The guidelines are also clear that in order to
receive an extended HPI, a provider must document at least four elements of the HPI or
the status of at least three chronic or inactive conditions."
The Wisconsin Medical Society, considered a reliable source of physician-reviewed medical information, answers the question as follows:
Can one utilize the status of 3 chronic conditions when using the 95’ DG?
Per CMS, yes. Although this information is physically present in the 97’ DG it is also implied in the 95’DG.
Finally, NHIC, Corp, a Medicare Service Contractor serving 4 million beneficiaries provides the following guideline regarding Evaluation & Management/Consultations:
Q: Would the status of three chronic conditions qualify as an extended history of the present illness (HPI) under the Evaluation and Management
Guidelines?
A: The status of three chronic illnesses does qualify as an extended HPI under the 95 guidelines as well as the 97 guidelines.
See your CPT Manual (Current edition) for more information regarding history in the Evaluation and Management Guidelines section and be sure to check with you payer to learn their requirements
For more information on this topic, please see the following reference articles:
Medicare Physician Guide (CMS-July 2007)
Highmark Medicare Services FAQ (Reviewed 2/13/2008)
Highmark Medicare Services HPI Elements (Reviewed 05/13/08)
Wisconsin Medical Society FAQ (2008)
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