Medicare Compliance & Reimbursement - 2012 Issue 4
Reader Question: Score the HPI When the Patient Says there is Nothing is Wrong?
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Article Overview
This article addresses a medical coding documentation question focused on history of present illness scoring when the patient does not identify a complaint and family members initiate the emergency response. It is aimed at coding professionals and documentation reviewers who need to evaluate HPI element capture from narrative clinical notes. The discussion stays at a general documentation level and centers on how to interpret the source note for HPI completeness.
Why This Topic Matters
Accurate HPI assessment affects documentation quality and evaluation-and-management coding support, especially when the presenting concern comes from others rather than the patient. Readers can use this article to better understand how narrative symptoms and context are reflected in the chart.
What You Will Learn
- How to evaluate HPI documentation when the patient denies a problem
- How family-reported concern may influence the documented chief concern
- How narrative clinical notes can contain HPI elements even without a classic symptom complaint
- How coding reviewers think about completeness of present illness documentation
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Billing staff
- Physician practice managers
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