Part B Insider - 2010 Issue 7
Evaluation and Management: Scope Out Potential Level 4 and 5 E/Ms By Knowing Crucial HPI Facts
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Article Overview
This article focuses on how history of present illness documentation affects outpatient evaluation and management coding for physicians, especially general surgeons. It compares Medicare and CPT approaches to counting HPI elements, discusses brief versus extended HPI, and reviews who must document the HPI and related history components. The piece is relevant to coders, compliance staff, and clinicians who document or review E/M services.
Why This Topic Matters
Accurate HPI documentation can influence whether an E/M service supports a higher level of reporting, and misunderstanding payer-specific counting rules can affect code selection and compliance.
What You Will Learn
- How HPI documentation contributes to outpatient E/M history
- Why Medicare and CPT may differ in counting HPI elements
- How brief and extended HPI are distinguished at a high level
- Why provider documentation responsibility matters for HPI credit
- How HPI relates to other parts of the medical history documentation process
Who Should Read This
- Medical coders
- Compliance staff
- General surgeons
- Physicians documenting E/M services
- Revenue cycle professionals
Codes Discussed
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