Results 1 to 5 of 5

HPI Documentation

  1. Default HPI Documentation
    Medical Coding Books
    I do ER coding and have physicians who may document some HPI elements plus add this statement "have reviewed and agree with RN notes". My question is, if the physician doesn't have enough elements in their HPI documentation can I use the nurses notes to obtain more elements?

  2. Default Not for HPI
    The HPI is considered physician documentation only. Other History elememts such as ROS can be a hybrid of physicin and nurse documentation with an oversite statement. But not the HPI.

    Jim Strafford MCS-P CEDC

  3. Default
    Thank you for your reply. Another questions, can I go back to the physicians and have them add the additional documentation in an addendum prior to coding the chart (these charts are EMRs)?

  4. Default
    I've went back to the DR and asked him to fill in the missing information. I just try to make sure I do it right away so that the patients case is still fresh on his mind.

  5. Default Depends


    Most ED Coding organizations do not do this. This is usually viewed as a compliance issue. So if the doc only documents 3 HPI and you return the chart looking for a fourth, what is the reason besides being able to code a higher level? I have seen one organization do this. They are very careful to make it clear that they are looking only to have charts complete based on the clinical presentation, not to code higher. Another issue is timing. If there is a way you can return these charts close to real time, it passes the compliance sniff test a bit more. Usually this is unrealistic unless you are coding on site. I've reccomended at times that someone is trained on site to audit charts. This might be worth doing.
    Hope this helps.


Similar Threads

  1. HPI and CC documentation
    By clopez in forum Billing/Reimbursement
    Replies: 2
    Last Post: 08-12-2015, 05:54 PM
  2. Documentation in HPI
    By Nkeith in forum Auditing General Discussion
    Replies: 1
    Last Post: 04-22-2015, 05:24 AM
  3. HPI documentation
    By cheryldudley8 in forum E/M
    Replies: 3
    Last Post: 02-24-2015, 03:14 PM
  4. HPI Documentation - review of ultrasound
    By SHobbs in forum Auditing General Discussion
    Replies: 0
    Last Post: 02-18-2013, 10:17 AM
  5. HPI documentation
    By gkhan in forum E/M
    Replies: 2
    Last Post: 12-16-2009, 01:50 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.