decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Answer_Book / Documentation_Guidelines_for_EM_Services / HISTORY_OF_PRESENT_ILLNESS_(HPI)
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Article Overview
This reference covers documentation guidance for the History of Present Illness (HPI) within evaluation and management services. It is intended for coders, auditors, clinicians, and documentation reviewers who need a high-level understanding of what the HPI is, the broad elements used to describe it, and how brief and extended histories are distinguished in documentation guidance.
Why This Topic Matters
Accurate HPI documentation supports evaluation and management record completeness and helps reviewers assess whether the clinical narrative includes the appropriate level of detail.
What You Will Learn
- What the History of Present Illness is in documentation terms
- Which broad elements are used to describe an HPI
- How brief and extended HPI documentation is differentiated at a high level
- How chronic or inactive conditions may factor into an extended HPI
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement staff
- Physicians and other clinicians
- Compliance reviewers
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