tci ED Coding & Reimbursement Alert - 2014 Issue 10

Documentation Strategies: Make Some Quality Time to Understand the Context of HPI Elements to Avoid Severe Audit Penalties

Use the right terms to master this important E/M component which is a frequent audit target.  If History of Present Illness (HPI) was the first component of E/M coding you learned, you could be overdue a refresher. Often, it’s HPI that trips up ED coders in audits and is the one of the biggest reason for down-coded claims. Read on for a return to fundamentals for capturing the HPI. Get specific: We know from the 1995 CMS documentation guidelines that the HPI is a chronological description of the development of the patient’s present illness from the...

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