Outpatient Facility Coding Alert - 2016 Issue 3
Case Study: Get Elemental to Gain Knowledge on HPI Levels
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Article Overview
This article is a practical coding discussion for office evaluation and management (E/M) documentation. It reviews how HPI element lists can differ between Medicare/Medicaid and CPT-based guidance, and it uses short case studies to show how documentation is assessed at a high level for brief versus extended HPI. The piece is most relevant to coders, auditors, and compliance staff who need to understand payer-specific documentation expectations.
Why This Topic Matters
HPI documentation affects E/M level selection, so understanding payer-specific element counts helps reduce overcoding, undercoding, and audit risk.
Article Sections
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Line Up Element List by Payer
Introduces payer-based differences in HPI element lists and notes that guidance may vary between Medicare/Medicaid and other payers. Also addresses the importance of confirming payer-specific documentation expectations.
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Case Study 1: Brief HPI
Presents a short documentation example used to illustrate how a limited review of HPI elements is assessed. Focuses on the basic structure of a brief HPI case study.
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Case Study 2: Extended HPI
Presents a longer documentation example used to illustrate how a broader review of HPI elements is assessed. Focuses on the structure of an extended HPI case study.
What You Will Learn
- How HPI element lists can vary by payer
- How brief HPI is discussed in office E/M documentation
- How extended HPI is discussed in office E/M documentation
- Why payer-specific documentation review matters for coding accuracy
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Healthcare consultants
- Physician practice staff
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