Decoding HPI: How to Increase Audit Accuracy

A patient’s history is a critical component to a physician for determining the etiology of a patient's problem. That’s why a history of present illness (HPI) is required in some form for every Evaluation and Management service.

The HPI of the encounter should include a patient’s symptoms and what they’re experiencing due to their chief complaint. There are eight distinct elements possible for these symptoms, including:

• Location
• Timing
• Duration
• Associated signs and symptoms
• Severity
• Modifying factors
• Context
• Quality

Don’t forget that the information should pertain to the chief complaint. If the record is unclear or lacking relevant information then it becomes open to interpretation and this is why the HPI portion of the medical record is one of the hardest areas of E/M auditing to get a consensus on. It’s hard to be consistent when the words in the medical record are subject to interpretation. And you end up in situations where coder Barbara interprets a patient’s medical records wildly different from how Tom or Mary the auditors interpret it. The subjectivity can seriously hinder our ability to correctly code or conduct accurate audits.

Tune into our free webinar, E/M Auditing: A Practical Guide to History of Present Illness, for details on handling the sticky HPI portion of medical records and to learn the impact of HPI, what words go with which HPI element, controversy over associated signed and symptoms and review of systems.