FAQ #22
       
What are the rules for completing the HPI using the 1995 E/M guidelines vs. the 1997 rules?

Answer: The official answer is known, but the practical answer may depend upon your Medicare carrier.

The physician may choose to use the 1995 or the 1997 E/M guidelines when completing their documentation.

The 1995 E/M Guidelines: HPI

The 1995 E/M guidelines define the HPI as follows:

The HPI is a chronological description of the development of the patient's present illness from
the first sign and/or symptom or from the previous encounter to the present. It includes the
following elements:

• location,
• quality,
• severity,
• duration,
• timing,
• context,
• modifying factors, and
• associated signs and symptoms.

Brief and extended HPIs are distinguished by the amount of detail needed to accurately
characterize the clinical problem(s).

• A BRIEF HPI consists of one to three elements of the HPI.
• An EXTENDED HPI consists of four or more elements of the HPI.
  

(1995 E/M guidelines: p. 9)

So, at first glance, it appears that you MUST use the so-called HPI elements in order to complete either a brief or an extended HPI. This would make it practically impossible to qualify for any level of HPI (and therefore any level of history) in patients who do not present with a somatic complaint which may be further described using the HPI elements. This is bad.

But, if you look at the bottom of the page, the following DG (which stands for documentation guidance) is included under the category of an extended HPI:

• The medical record should describe four or more elements of the present
  illness (HPI) or associated comorbidities.

This appears to be saying that you CAN complete an EXTENDED HPI by commenting on four associated comorbidities. The definition of comorbidities is not provided. Nor is there any guidance about what you have to say about the comorbidities. Still, this does open the window for completing an EXTENDED HPI using the 1995 E/M guidelines without having to use the HPI elements.

Unfortunately, it is not clear if you can qualify for a BRIEF HPI if you describe less than four comorbidities. This is not addressed in the 1995 E/M guidelines. However, it has become standard practice among most auditors to give credit for a BRIEF HPI if less than four comorbidities are commented upon. (CAUTION: Before assuming this to be the case, you should confirm this with your Medicare carrier.)

The 1997 E/M guidelines: HPI

The 1997 E/M guidelines define the HPI as follows:

The HPI is a chronological description of the development of the patient's present
illness from the first sign and/or symptom or from the previous encounter to the
present. It includes the following elements:

• location,
• quality,
• severity,
• duration,
• timing,
• context,
• modifying factors, and
• associated signs and symptoms.

BRIEF and EXTENDED HPIs are distinguished by the amount of detail needed to
accurately characterize the clinical problem(s).

• A BRIEF HPI consists of one to three elements of the HPI.
  
• An EXTENDED HPI consists of at least four elements of the HPI or the status of at least
  three chronic or inactive conditions.

(1997 E/M guidelines: p. 9)

Here, they explicitly state that you can qualify for an EXTENDED HPI by commenting on the status of three or more chronic or inactive problems, instead of having to use the HPI elements. This would make it easier to qualify for the EXTENDED HPI in patients who do not present with a specific somatic complaint (office follow-up visits, hospital progressn notes, etc.).

So, it is clear that you can qualify for an EXTENDED HPI by commenting on three problems. Unfortunately, similar to the 1995 E/M guidelines, there is no mention of being able to qualify for a BRIEF HPI by commenting on the status of LESS than three problems. However, it has become standard practice for most auditors to give credit for a BRIEF HPI if the status of less than three chronic or inactive problems are decribed. (CAUTION: Before assuming this to be the case, you should confirm this with your Medicare carrier.)

SUMMARY

It appears that EITHER the 1995 or the 1997 E/M guidelines will allow you to complete the HPI by using the HPI elements. The 1995 E/M guidelines state that you can qualify for an EXTENDED HPI by including comments about four or more comorbidities. The 1997 E/M guidelines state that you can qualify for an EXTENDED HPI by commenting upon the status of three or more chronic or inactive problems. Neither the 1995 nor the 1997 E/M guidelines state that you can qualify for a BRIEF HPI by commenting on less than four comorbidities or less than three chronic or inactive problems, although this is widely assumed to be the case.