HPI Demonstrates Medical Necessity

by John Verhovshek, MA, CPC
Medical necessity is demonstrated based on information captured in the history of present illness (HPI). Documentation quality matters more than quantity. The information should be relevant to the presenting problem(s), and it should seek to answer the questions each HPI element asks, as follows:
Location: e.g., Back pain, Nasal Congestion
Quality: e.g., sharp or shooting pain, dry cough
Severity: e.g., extremely nauseated, moderate pain
Duration: e.g., Onset two weeks ago
Timing: e.g., Worse in the mornings, Occurs constantly
Context: e.g., Dizzy upon standing, Worse after excersice
Associated Signs/Symptoms: e.g., a chief complaint of nausea may be accompanied by associated symptoms of vomiting and diarrhea
Modifying Factors: e.g. No relief from OTC meds, Improves with rest
Note that only the performing provider may document HPI. Copying the nurse’s notes or patient responses in a questionaire does not count.

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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