The 20-year-old evaluation and management (E&M) documentation guidelines are full of different components and elements, all of which must be reviewed in order to ensure that services billed were appropriately documented.
If you look at the full list of components (history, exam, and medical decision-making) and their subcomponents, there are 66 different scoring elements. Then you have to consider all the possible thousands of combinations possible when “adding” those elements. All 66 elements have ambiguities and complex guidelines that are not always clear in any given scenario, so you should discuss each element with your auditors and agree on setting specific auditing policies for them. In an earlier article, I discussed several of these components, including the chief complaint and the guidelines, and suggested policies to accompany them.
In this article, I will discuss the history component and the individual elements of the history of present illness (HPI).
The HPI of the encounter should include symptoms the patient is experiencing due to his or her chief complaint.
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