Pediatric Coding Alert

Review your coding basics to potentially move to a higher level. Thinking of starting routine chart audits to decrease your practice's compliance risk? Use this guide to nail down chart notes' history of present illness (HPI) elements to ensure they support the selected code level. Count These HPI Items For coding purposes, HPI is the chronological description of development of the present illness from first sign or symptom, or prior encounter, to present, explains Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. With HPI recording, the pediatrician should document the unique situation of each patient at each encounter to clearly substantiate the medical necessity of the service(s) rendered that day. Depending on the payer, there are seven or eight HPI elements. For Medicaid payers, the HPI elements are: • Location • Quality • Severity • Duration • Timing • Context • Modifying factors • Associated [...]