tci Medicare Compliance & Reimbursement - 2010 Issue 14

Assess HPI Level to Help: Narrow E/M Choice

Differentiate brief history of present illness from extended with these tips. Question: Our coding staff has a disagreement about how to differentiate a brief history of present illness (HPI) from an extended HPI. Our office manager feels that our practice has had to downcode some claims from a higher E/M level to a lower one simply because the physician either isn't documenting the HPI completely, or because our coding staff downgrades the HPI. We'd love some advice on what the difference is.Answer: You can distinguish between brief and extended HPIs based on the detail the physician needs to...

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