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Fam Pract Manag. 2002;9(8):14-16

In the FPM article “How to Get All the 99214s You Deserve” (October 2001, page 43), Emily Hill, PA-C, wrote that under the 1995 documentation guidelines an expanded problem focused exam involves two to four organ systems and a detailed exam involves five to seven organ systems. She also implied that the “3+ chronic disease” rule, which defines the extended history of the present illness (HPI) as four or more elements of the HPI or the status of three or more chronic conditions, can be used under either the 1995 or 1997 versions of the guidelines. Ms. Hill based her statements on an earlier FPM article, “Important Changes in the Documentation Guidelines” (February 1996, page 50), which reported statements made by (then) HCFA staff in a public forum that the 1995 guidelines would be modified to incorporate these changes.

Unfortunately, HCFA (now the Centers for Medicare & Medicaid Services or CMS) never incorporated the changes, and a CMS staff member recently told us that no such change is in the works. Consequently, the 1995 version of the documentation guidelines makes no distinction between expanded problem focused and detailed exams in terms of organ systems/body areas; each may involve two to seven. The only distinction is that an expanded problem focused exam is “limited” and a detailed exam is “extended.” The 1995 guidelines also do not incorporate the “3+ chronic disease” rule in the definition of HPI.

Coding educators and consultants including Ms. Hill continue to teach and use the 1995 guidelines, making the distinction between expanded problem focused exams and detailed exams and using the definition of extended HPI that CMS staff described publicly in 1996. While there is a risk to following this unpublished advice, that risk is probably minimal given that the level of service may be justified on the basis of factors other than the exam and the HPI portion of the history and given the small percentage of claims that CMS actually reviews. In a worst-case scenario, CMS might downcode your claim by one level and ask you to refund the difference between what you were originally paid for the claim and the reimbursement amount for the lower level of service.

A reference was inadvertently omitted from the article “Achieving a More Minority-Friendly Practice” [June 2002, page 39]. The article should have cited the following as the source of the Cultural Competence Continuum: Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a Culturally Competent System of Care: Vol. 1. Washington, DC: Georgetown University, 1989.


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