Outpatient Facility Coding Alert - 2009 Issue 19
READER QUESTION :Count HPI, Or Risk Choosing Wrong E/M Level
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Article Overview
This reader question-and-answer article covers the documentation elements used to evaluate history of present illness in the context of E/M services. It explains the general HPI element-counting framework, notes a CPT-specific variation, and gives a brief documentation example to illustrate the topic for coding professionals and clinicians.
Why This Topic Matters
Accurate HPI assessment affects whether a history component supports a selected E/M level. The article helps readers review documentation consistently and avoid mismatches between the note and the billed service level.
Article Sections
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Question
Introduces the reader’s question about HPI elements and why they are counted for coding purposes.
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Answer
Explains the general relationship between HPI element count, history level, and E/M service selection.
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Checklist
Lists the broad categories used to review HPI documentation for coding evaluation.
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Note
Provides a CPT-specific clarification about the HPI element count.
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Example
Shows a brief documentation example used to illustrate HPI element counting in practice.
What You Will Learn
- How HPI is reviewed in relation to E/M history documentation
- Which broad types of information are counted as HPI elements
- How a CPT-specific note affects the element count framework
- How a documentation example can be evaluated at a high level
Who Should Read This
- Medical coders
- Coding auditors
- Physician documentation specialists
- Clinicians who document E/M services
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