AMA CPT® Assistant - 1996 Issue 4 (April)

Understanding the History of Present Illness: The Seven Dimensions (April 1996)

April 1996 page 5 Coding Commentary Understanding the History of Present Illness: The Seven Dimensions Since the publication of the Evaluation and Management (E/M) documentation guidelines, many questions have been raised concerning the seven dimensions mentioned in the history of present illness (HPI). The medical history provides essential information for diagnosis and management, and varies by each individual patient and problem(s). Patients usually express their problems as symptoms (eg, pain or discomfort), or signs (eg, noticeable physical abnormalities, like a lump, cut or bruise, murmur, or friction rub). The further elaboration of any symptom requires attention to some or...

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CPT® Assistant content is the official source for CPT® coding guidance. It is an instrumental tool when appealing insurance denials and validating coding to auditors. Monthly issues and an extensive archive provide comprehensive guidance on proper CPT® coding for past, present and upcoming code set releases. Archives date back to 1990 for historical use of codes, changes, rationales, coding tips and trends in the industry.

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