Part B Insider - 2019 Issue 11
Reader Question: Know Guidelines to Calculate HPI With Elements or Chronic Conditions
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Article Overview
This reader question and answer discusses evaluation and management history documentation, focusing on how HPI is counted under the 1995 and 1997 documentation guidelines and how CMS guidance addresses use of those standards together in Medicare documentation. It is aimed at coders, auditors, and clinical documentation staff who need to understand what the article covers before reading the full guidance.
Why This Topic Matters
Accurate E/M history documentation affects audit readiness and consistent documentation practices. The article helps readers understand the scope of HPI counting rules and the role of provider-documented history.
What You Will Learn
- How the article frames HPI counting under older E/M documentation guidelines
- What CMS guidance is cited in relation to mixed guideline use
- Why provider documentation of the HPI portion matters for audit purposes
- How the article distinguishes between documentation standards and clinical staff contributions
Who Should Read This
- Medical coders
- E/M auditors
- Clinical documentation staff
- Physicians and other providers
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