Outpatient Facility Coding Alert - 2012 Issue 10
Reader Question: Don't get too creative when counting HPI elements
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Article Overview
This reader question reviews a sample history of present illness and discusses how to assess the documented HPI elements without over-interpreting the note. It is aimed at coders and billing staff who work with evaluation and management documentation and need a general understanding of HPI element counting.
Why This Topic Matters
Accurate HPI element counting affects evaluation and management documentation review and helps avoid unsupported coding judgments based on incomplete or ambiguous wording.
What You Will Learn
- How to review a sample HPI for documented elements
- How to think about location and associated signs and symptoms in HPI documentation
- Why incomplete documentation can limit the level of HPI supported by the note
- How reader questions can be used to clarify documentation concepts for coding review
Who Should Read This
- Medical coders
- Billing staff
- Compliance staff
- Clinical documentation reviewers
- Evaluation and management specialists
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