Using an Extended History in Your Medical Billing

You can use the 1997 audit guidelines that state an extended history for a patient can be created by updating the status of at least three chronic or inactive conditions that the patient has or has had. It is not imperative that the information be placed in the history of present illness (HPI) section.

However what is imperative is that your medical billing reflect the medical documentation of all illness that you choose to use – both past or present- to create an extended history of illness. For audit purposes it is helpful to have the notations in both the HPI section and the assessment section. Most physicians will make their notes in the assessment section, it will be up to the medical biller usually to make sure that the proper documentation is in the HPI section of the file.

In the 1997 the guidelines were updated to remove the requirement that in order to report higher level services you do not have to show the four elements of HPI for an extended level HPI as it is an ongoing condition that the patient lives with on a daily basis such as asthma or diabetes. Additionally, the 1997 guidelines may allow you to report a higher-level E/M code for encounters that involve periodic prescription renewals without the MD having to go into as much detail.

The ongoing illnesses will need to be notated appropriately, such as reporting diabetes is “stable” or asthma is “active but stable” indicating the patient still requires treatment but the disease is not worsening.

Remember, make your medical necessity key in this type of claim and make sure that you tie in medical necessity of the visit to the ongoing condition where necessary with the proper documentation.

View all Articles by: Melissa Clark, CCS-P