tci ED Coding & Reimbursement Alert - 2022 Issue Q2

You Be the Coder: Can You Tally the HPI Elements in This Note?

Question: Thanks for your article on the history of present illness (HPI) last month. I have a follow-up question on this topic and how it relates to reporting ED-based evaluation and management (E/M) services. I’m auditing a note that states: “CC: A patient seen in the office complains of left ear pain. HPI: Patient complains of dull ache in left ear over the past 24 hours.” Would “dull ache” as in ear pain count as one or two HPI qualifiers? Does the note support brief or extended history of illness (HPI)? Maryland Subscriber Answer: Dull...

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