READER QUESTIONS:
Follow 'Quality' Examples for HPI
Published on Thu May 28, 2009
Question: Can we use the patients diagnosis as quality under HPI? Maryland Subscriber Answer: No. According to CMSs Evaluation and Management Services Guide, examples of quality include aching, burning, radiating. The documentation should include words describing the quality of any symptoms. Also, the guide says HPI (history of present illness) is a chronological description of the development of the patients present illness from the first sign and/or symptom or from the previous encounter to the present. The diagnosis itself does not fit the bill. Resource: Check out the Guide at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.
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