Did you know that CMS considers medical necessity the primary criterion for payment? When it comes to problem-based Evaluation & Management services, proper documentation of the History of Present Illness is absolutely crucial in establishing medical necessity. And it turns out that HPI documentation is frequently deficient, lowering reimbursement and opening providers up to penalties and repayment.
Correctly documenting HPI is not difficult. There are two approaches, depending on the patient's presenting problem:
Below, you'll find a list of the CMS approved HPI descriptors with examples of each. As a mnemonic, you can clip out the list and store it on your smartphone, or print it out and tape it in a handy location.
HPI DESCRIPTORS (with examples)
Documenting at least four of these descriptors at every patient visit will result in a more robust history, will protect you during audits, and will guarantee that something as minor as a deficient HPI does not interfere with your reimbursement.
Kimberly A. Sherman, MA, CPC - Reimbursement warrior and HIPAA guru.