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Evaluation and management: documentation for accurate code selection

Staff Development Weekly: Insight on Evidence-Based Practice in Education, January 9, 2004

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History of present illness (HPI) is a chronological description of a patient's present illness from the first sign and/or symptom or from the previous encounter to the present. Both 1995 and 1997 CMS Guidelines require documentation of at least one but not more than four of the eight elements recognized in the HPI. The HPI is one of the most common areas of documentation insufficiencies. Creating templates or documentation systems can help prevent problems. Many physicians will make a habit of obtaining primarily the same four elements each time. The same elements may not always apply, and physicians will default to using other elements. It is not unreasonable to document at least four elements even on the low-acuity patients.

Editor's note: The above is an excerpt from the new online course "Evaluation and Management: Documentation for Accurate Code Selection." For more information on this course and a sample HPI, as well as other Compliance courses go to www.hcprofessor.com and click on Compliance.

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