Medicare Compliance & Reimbursement - 2016 Issue 11
Clip and Save: Use This Template to Get HPI Info
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Article Overview
This article is a practical coding and documentation guide for professionals who support evaluation and management (E/M) services. It focuses on how to obtain a more complete history of present illness (HPI) by asking targeted follow-up questions after the chief complaint is established, including guidance on common HPI elements and additional questions that help characterize ongoing or longstanding symptoms. The article is relevant to coders, auditors, clinical staff, and providers who document E/M histories.
Why This Topic Matters
Accurate HPI documentation affects the completeness of E/M records and supports consistent clinical communication and coding-related review. This piece helps readers understand what information to gather so the visit history is more thoroughly documented.
Article Sections
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Get More Specific With Queries After CC
Introduces follow-up questioning after the chief complaint is identified. The section organizes the main HPI elements and explains the kinds of information clinicians may seek for each one.
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Ask These Extra Questions to Round Out HPI
Adds broader follow-up questions that can help complete the HPI, especially when symptoms are chronic or longstanding. The section emphasizes additional context and patient perspective.
What You Will Learn
- How structured questioning supports collection of HPI information
- Which broad HPI elements are commonly explored during an E/M history
- How additional questions can help document chronic or longstanding symptoms
- How patient perspective can add context to the present illness narrative
Who Should Read This
- Medical coders
- Coding auditors
- Physicians and other providers
- Clinical documentation staff
- Medical office staff involved in E/M documentation
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