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Pulmonology Coding Alert

Reader Questions:

Count HPI to Choose Right E/M Level

Published on Tue Jul 28, 2009

Question: I am having some trouble understanding the elements of history of present illness (HPI) as they relate to the 1995 documentation guidelines. What exactly are the HPI elements, and why do coders have to count them? Idaho Subscriber Answer: You need to count the HPI elements because they are an important part of the history component of E/M services. A brief HPI consists of one to three elements, whereas extended HPI requires four-plus elements. The physician must perform an extended HPI in order to satisfy the requirements for a detailed or comprehensive history. Extended HPI does not guarantee that you can report high-level E/M codes, but it does make reporting them possible. The physician still has to satisfy the other elements of the service before choosing high-level codes. Checklist: For coding purposes, HPI is an ordered description of the patient's current malady. When counting elements, check to see how [...]
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