Using History of Present Illness to Drive the Examination

History of Present Illness (HPI) and OPQRST One of the most important elements of a patient evaluation is collecting his/her History of Present Illness (HPI). The HPI elements that a patient normally presents with have a direct clinical correlation to the type and severity of the condition for which they are being treated. These elements...
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Medically Appropriate History and/or Examination Defined

Defining Medically Appropriate History and/or Examination  With the release of the new Evaluation and Management (E/M) Guidelines in 2021, gone are the days of determining the E/M code by counting bullets in an examination and levels in a history. The new guidelines indicate that coding is established based on either the level of Medical Decision...
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