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Otolaryngology Coding Alert

Reader Questions:

Assess HPI Level to Help Narrow E/M Choice

Published on Thu Apr 08, 2010

Question: How does a brief history of present illness (HPI) differ from an extended HPI?Michigan SubscriberAnswer: You can distinguish between brief and extended HPIs based on the detail the otolaryngologist needs to accurately characterize the clinical problem(s). Specifically, a brief HPI consists of one to three elements, but an extended HPI consists of four or more elements, according to the CMS "1995 Documentation Guidelines for Evaluation & Management Services" (www.cms.gov/MLNProducts/Downloads/1995dg.pdf).Important: Remember when choosing an E/M code that history is only one component, and you must consider the level of exam, medical decision making, and the nature of the presenting problem as well before settling on the correct E/M code.An extended HPI is necessary to reach a detailed or comprehensive history, and, thus, qualify for the higher levels of E/M services. For instance, established patient office visit code 99214 (Office or other outpatient visit for the evaluation and management of [...]
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