In Coding
Jun 19th, 2017
To determine what to include in the History of Present Illness (HPI), keep these questions in mind. Location – Where is the pain? Where is the problem? Ex. back pain, nasal congestion Quality – Please describe your symptoms (Action words) Ex. sharp or shooting pain, dry cough Severity – What is the patient’s level of ...
In Billing
Feb 19th, 2016
When billing Medicare, a provider may use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management (E/M) CPT or HCPCS Level II code. For services performed on or after September 10, 2013, however, physicians may use the 1997 documentation guidelines for an extended history of present illness ...
In Audit
Jul 15th, 2015
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 ...
In Billing
Jul 15th, 2015
by John Verhovshek, MA, CPC Follow-up visits with critically (or terminally) ill patients won’t necessarily call for a high-level E/M service. For example, when a patient is in the middle of chemotherapy, and no adverse reactions are reported or no new complaints are noted, the visit would not merit a high level just because there ...
In Billing
Mar 9th, 2015
Sometimes, at a scheduled preventive visit, the patient mentions a new or worsened condition. If the patient complaint requires additional workup, beyond that usually associated with the preventive service, you may choose to report a problem-focused visit in addition to the preventive service. The CPT® codebook instructs: If an abnormality is encountered or a preexisting ...