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Urology Coding Alert

Evaluation and Management:

Use These Questions to Capture HPI for Full Reimbursement

Get your urologist to collect the information you need with this handy list. In Urology Coding Alert Vol. 12, No. 4, you learned how to use history of present illness (HPI) to determine the E/M level reportable for your urologist's services. Now, take a look at this checklist to help determine the HPI level a service meets. When counting elements of HPI, check to see how many of these eight questions your urologist answers in the notes: What is the location of the problem? (location of pain, mass, or organ involved) What is the quality of the problem? (nature of the pain, such as dull or colicky) How intense is the pain or problem? (severity) How long has the patient had the problem? (duration) Is the problem better or worse at any time of the day? (timing) What is the setting or circumstances in which the problem occurs? (context) What [...]


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