tci Medicare Compliance & Reimbursement - 2007 Issue 43

Coding Coach: Follow These HPI Tips For Bulletproof E/M Coding

Hint: Simply mentioning inactive conditions could lead you down the wrong path The 1997 documentation guidelines state that if your physician can update the status of at least three chronic or inactive conditions, the documentation would meet the criteria for an extended "history of present illness" (HPI). Get up to speed on how your provider should document these cases -- and how you should code them. Although some physicians reference the patient's chronic conditions in the assessment section of the medical decision-making (MDM) section, some physicians choose also to discuss the chronic diseases in the HPI section of notes...

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