decisionhealth Newsletters, Coder Pink Sheets - 2004 Issue 6 (June)
It's not double-dipping to count multiple problems in HPI
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Article Overview
This article explains a Medicare/CMS-based discussion of history documentation for office E/M services. It is aimed at coders and clinicians who document HPI and ROS in cases involving multiple presenting problems, and it covers broad guidance on counting HPI elements, avoiding overlap within the history, and understanding how payer review may view related documentation.
Why This Topic Matters
Accurate history documentation affects E/M level selection and compliance. The article helps readers understand how to recognize when multiple presenting problems may support a fuller HPI without overcounting the same information.
What You Will Learn
- How multiple presenting problems can be reflected in the HPI
- How HPI elements are generally organized in Medicare guidance
- How overlap between HPI and ROS may be viewed by some payers
- How to avoid counting the same documentation element more than once
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- E/M specialists
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