tci ED Coding & Reimbursement Alert - 2010 Issue 4

ED-Specific Exception Allows You to Sidestep Some HPI Rules

Use these FAQs to achieve level 5. A patient reports to the ED in such severe respiratory distress that she cannot communicate during the history of present illness (HPI) portion of the E/M service. The patient also presents to the ED alone via ambulance, meaning there was no one else to speak for her. How can a coder decide on the history level for this ED E/M service? Knowing an important exception to the HPI rules in ED settings will help you accurately report  these incidents. . When a physician documents that an HPI [history of present illness] is unobtainable...

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