Reader Questions: Get Elemental When Determining HPI

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Note:  The following article synopsis was NOT provided by AAPC. It was created by Find-A-Code/innoviHealth.

Article Overview

This short Q&A article reviews the basic elements used to determine history of present illness (HPI) in evaluation and management documentation. It is aimed at coding and auditing professionals who want to understand how HPI data elements are described so they can better evaluate documentation completeness and chart review outcomes.

Why This Topic Matters

HPI documentation can affect the accuracy of evaluation and management service reporting, so understanding the component elements helps reviewers assess whether a chart supports the intended service level.

What You Will Learn

  • The core elements that make up an HPI review
  • How documentation quality can affect E/M auditing
  • What types of patient-history details are commonly considered in HPI assessment
  • How reviewers think about completeness of symptom and complaint documentation

Who Should Read This

  • Medical coders
  • Coding auditors
  • Compliance staff
  • Physician documentation specialists
  • Revenue cycle professionals

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