BC Advantage - 2016 Issue 8
History of Present Illness
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Article Overview
This article is a practical overview of the History of Present Illness (HPI) within Medicare documentation guidelines. It is aimed at coders, auditors, and clinicians who need to understand what HPI covers, how it is documented, and how its completeness is assessed in evaluation and management records. The discussion focuses on the general components of HPI, provider documentation expectations, and the distinction between brief and extended HPI.
Why This Topic Matters
HPI documentation affects how evaluation and management records are supported, so understanding the scope and documentation requirements helps identify whether a note is complete enough for audit and coding review.
What You Will Learn
- What the History of Present Illness represents in documentation guidance
- The broad components that may be included in an HPI
- Who is expected to document the HPI
- How HPI completeness is generally characterized
- How multiple complaints can factor into HPI documentation review
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Clinicians
- Documentation specialists
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