Tag Archives: HPI

E&M Guidelines: HPI and Chronic Conditions

Last month, I blogged about the History of Present Illness (HPI) portion of an E&M note. The HPI section details the specifics of why the patient is seeing their physician. Prior to that, I wrote about the two sets of E&M guidelines, specifically the different exams within those guidelines to guide physicians and/or coders to select a level of care provided during that visit. This month, I’d like to dig into the point at which these two sets of guidelines converge: chronic conditions.

The 1995 E&M documentation guidelines stipulate that to support the higher levels of care, a provider must document four or more elements of the HPI. The 1997 E&M documentation guidelines added a chronic conditions option. These guidelines state that a provider could document the status of three or more chronic conditions rather than four or more elements of the HPI. Continue reading

Alphabet Soup: Acronyms and E&M Coding

As healthcare professionals, we have a lot of acronyms to keep straight, don’t we? Feels like alphabet soup in my head some days. I’m reminded of a scene in the movie, Good Morning Vietnam, where Robin Williams’ character has an entire conversation using acronyms, making fun of the military jargon. We could do the same in healthcare, especially in E&M coding.

Today, let’s think a bit about HPI, not to be confused with PHI. If you have a translator in your head the way I do, these two don’t even sound the same, but for those outside the realm of coding, these acronyms can get confusing. PHI is Protected Health Information. HPI, or History of Present Illness, is the portion of the E&M (Evaluation and Management) visit during which the patient describes why they are seeing the physician. Continue reading