tci E/M Coding Alert - 2022 Issue Q2

Reader Questions: Try Your Knowledge Counting These HPI Elements

Question: I have a question about history of present illness (HPI) and how it relates to reporting ED-based evaluation and management (E/M) services. I’m auditing a note that states: “CC: A patient seen in the office complains of left ear pain. HPI: Patient complains of dull ache in left ear over the past 24 hours.” Would “dull ache” as in ear pain count as one or two HPI qualifiers? Does the note support brief or extended HPI? Massachusetts Subscriber Answer: Dull ache counts as two HPI elements. Ache is the symptom, and dull is the...

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