# HPI help



## dsmith06351 (Mar 4, 2010)

I know that the physician must document the HPI but can someone direct me to where I can find that in writing. I have looked in the 95 guidelines but I can't find anything that specifically states this. Any help is greatly appreciated.

Denise Smith CPC-A, CEMC


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## Pam Brooks (Mar 5, 2010)

Actually there are no guidelines that I've ever seen that state that an HPI _must_ be documented; the guidelines say that in order to code a new patient, consult, initial hospital visit (i.e any E&M that requires 3/3 key components) you must have an HPI documented.

There must be a chief complaint, though.  

So if you are coding an E&M with no HPI, but you have an exam and MDM, you technically have the criteria for an established patient OV, or a subsequent hospital visit.  

Of course, we'd love for all of our providers to document a clear, concise and legible SOAP note, but we have to work with what we get.  This is where an EMR is helpful; our particular software will alert the provider if they forget to document any one of the key components. Otherwise, we continue to provide education to our docs and remind them to document a complete note! 


However, if you do find CMS or AMA guidelines somewhere that indicate that an HPI is mandatory, can you please post the link?  Thanks, Pam


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## dsmith06351 (Mar 5, 2010)

I still haven't found anything, but what is happening in our office is the nurse is taking a brief history before the doctor goes in to see the patient. The doctor reviews what the nurse has written with the patient but does not write their own history because it is already written down. I need to show to the doctor that in order to count as HPI they must write it not the nurse.

Denise Smith CPC-A, CEMC


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## chetubig001 (Mar 5, 2010)

http://emuniversity.com/HistoryofPresentIllness.html

Scroll all the way to the bottom in which it states:

E/M University Coding Tip: The physician MUST personally complete and record the HPI.  The HPI is the ONLY part of the history which CANNOT be recorded by ancillary staff. 

This is a great website.


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