ED Coding and Reimbursement Alert

Get the story straight on this often misunderstood but very important E/M component.If History of Present Illness (HPI) was the first component of E/M coding you learned, you could be overdue a refresher. Often, it's HPI that trips up ED coders in audits and is the one of the biggest reason for down-coded claims. Read on for a return to fundamentals for capturing the HPI.Get specific: We know from the 1995 CMS documentation guidelines that the HPI is a chronological description of the development of the patient's present illness from the first sign or symptom to the present encounter. It can be an expansion on the chief complaint and really introduces the reason that the patient is seeking treatment. Unlike the ROS and PFSH elements of a history, the HPI must be documented by the reporting provider. Additionally, there should be documentation of a chief complaint, which is often a [...]