History of Present Illness in 2021

Q:

Should we continue to require HPI information for each problem in 2021?

A:

Answer: While we are certainly thankful for the 2021 guideline changes, we should not be so quick to put HPI and exam on the shelf. Codes 99202-99215 are defined as requiring medically necessary history and exam. While the extent may be determined by the clinician, the information documented should still convey current status and the need for interventions for each condition addressed. If BCA could vote to keep one component of the previous guidelines, it would decidedly be the Incoming Status rule for HPI. BCA recommends keeping this as a best practice for documentation. This approach will tell a clear story of today’s encounter and assist with capturing medical necessity for the service and any resultant orders.

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