History of Present Illness (HPI)

“The HPI is one element of the patient’s medical history.  The evaluation and management (E/M) guidelines define the HPI as,     “ …a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.””

This FAQ addresses the following:

  1. What is the history of present illness (HPI)?
  2. How is the HPI different from the chief complaint (CC)?
  3. What are the components of the HPI?
  4. Does a list of negative responses satisfy the HPI documentation requirements?
  5. Are there various levels of the HPI?
  6. Does the extent of the HPI impact the level of service of an E/M code?
  7. Do the eye codes (920xx) require documentation of the HPI?
  8. May the technician perform the HPI?
  9. How should the chart note look?
  10. May the HPI be written by a scribe?
  11. Must the physician personally perform the ROS and PFSH also?

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