Part B Insider - 2013 Issue 2
Clip and Save: Get the HPI Information You Need With This Checklist
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Article Overview
This article is a brief documentation reference for clinicians, coders, and compliance staff who need to evaluate history of present illness (HPI) content in medical notes. It explains the general types of HPI elements to look for and highlights that payer guidance may differ under CPT-based policies, making it useful for anyone validating E/M history documentation.
Why This Topic Matters
HPI documentation can affect evaluation and management reporting, so knowing what information is present in the record helps teams assess whether the note supports the level of service under the applicable guidance. The article is relevant to people who review provider documentation, train clinicians, or audit E/M records.
What You Will Learn
- How to review a note for common HPI documentation elements
- Which broad types of patient history details are considered in HPI assessment
- That payer guidance may differ in how HPI elements are counted
- How this checklist can support documentation review for E/M services
Who Should Read This
- Medical coders
- Clinical documentation improvement staff
- Compliance auditors
- Physicians and other providers
- Billing staff
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