decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / History of present illness or HPI
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Article Overview
This premium article covers the 1995 E/M documentation framework for the history of present illness, including the core elements used to characterize a patient’s current problem and the distinction between brief and extended HPI documentation. It is useful for coding and compliance professionals, clinicians, and auditors who need to understand how the guideline is presented and how the documentation standard is described in the source material.
Why This Topic Matters
Understanding the HPI portion of the 1995 E/M guidelines helps readers evaluate whether documentation supports the level of history recorded in a medical encounter. The article is relevant for anyone reviewing E/M documentation requirements or training staff on history element completeness.
What You Will Learn
- What the history of present illness is intended to capture
- Which broad elements are included in an HPI
- How the article distinguishes brief and extended HPI documentation
- What documentation guidance is stated for HPI completeness
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians and clinical documentation staff
- Healthcare educators
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