General Surgery Coding Alert

Watch out for CPT/Medicare differences when counting HPI elements.If you're not accurately accounting for the history of present illness (HPI) documented by your general surgeon, you could be missing out on opportunities to report level 4 or 5 E/M visits. Ensure you're not missing higher-pay possibilities by reviewing this guide to capturing HPI elements.Brush Up on What Qualifies as an HPI ElementHPI is one of the three parts comprising an outpatient E/M history. It describes the patient's present illness or problem, from the first sign/symptom to the current status, and typically drives your surgeon's decisions about the physical examination and treatment."The information gathered during the physical exam (PE) portion of a patient's evaluation often only shows a very limited picture of the patient's problem. However, speaking with a patient and gathering the history of the patient's problem can relate the entire picture," explains Amanda S. Stoltman, CCSP, compliance coder in [...]