In Coding
Feb 1st, 2019
As a required component of any E/M service, the history of present illness (HPI) is a chronological description of the development of the patient’s present illness, from the first sign or symptom, or previous encounter, to the present. Both the 1995 and 1997 Evaluation and Management Documentation Guidelines quantify the HPI by: Location: Patient statements regarding ...
Correct bad habits before your E/M services claims are audited. by Tim Stelma, BA, CPC, CPMA, AAPC Professional Auto-fill and self-leveling functions in electronic healthcare records (EHRs) have led to higher utilization of upper-level evaluation and management (E/M) services. This has not gone unnoticed by insurance carriers. To dodge a large take-back resulting from a ...
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 CMS
Dec 5th, 2016
Centers for Medicare & Medicaid Services (CMS) evaluation and management (E/M) Documentation Guidelines (DG) allow providers to use an extended history of present illness (HPI), as defined by the 1997 evaluation and management documentation guidelines (DG), with the remaining elements of the 1995 DG. This means that “the status of three or more chronic conditions” ...
In Coding
Oct 3rd, 2016
Nothing in either the 1995 or 1997 E/M documentation guidelines state that you cannot count a single documented item in both the history and review of systems (ROS)—so called “double dipping.” Nothing in AMA/CPT® or Centers for Medicare & Medicaid (CMS) guidelines says so, either. If an item is clearly documented, you may count it ...