Instructions:

The business of medicine is the process of determining what is wrong with a patient who is seeking assistance.  A history of the present illness (abbreviated HPI) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain) of a patient. The physician will create written documentation of that history and then it is up to the Coding and Reimbursement Specialist to accurately determine the proper code for the history without either "upcoding" or "downcoding".  This Competency Assessment will give you an opportunity to work with documentation of an Evaluation & Management History of Present Illness.

Review this E & M Coding Tool.  Note the orange parts of the tool that specifically deal with the History portion of E & M Coding.  This tool may be helpful in determining from the medical documentation which level of coding should be used for this portion of the E & M Coding.  If you have questions, this is a good time to talk to your Content Expert about how to use this tool.

Assessment:

Open and then submit this document: E & M - HPI (Google Doc)