A limited HPI may not adequately support medical necessity.

Include sufficient detail regarding:

• • the patient’s symptoms
  • onset
  • duration
  • severity
  • modifying factors
  • associated signs and symptoms
  • progression
  • clinical impact when applicable

• Documentation should clearly describe the patient’s condition, clinical status, assessment, and plan of care.
• Ensure documentation demonstrates the complexity of the encounter and supports the reported diagnoses and level of service.

• Listing diagnoses alone does not support MDM.
• Document the provider’s assessment, differential considerations when applicable, treatment decisions, medication management, diagnostic testing ordered or reviewed, interpretation of results, follow-up plans, and risk associated with patient management.

• Services billed must be supported by complete and legible medical records.
• Failure to provide documentation upon request may result in claim denial or audit findings.

• When documentation identifies the affected side, report the diagnosis with the appropriate laterality.
• Avoid unspecified pain or joint injury diagnosis codes when documentation supports a more specific code.

• Only report diagnoses that are evaluated, assessed, treated, or otherwise managed during the encounter.
• Do not assign diagnosis codes solely from the patient’s problem list, past medical history, or medication list without supporting documentation in the current encounter.