Forum - Questions & Answers

May 12th, 2015 - shofner14

E/M Documentation

Can an exam element be mentioned in the HPI when documenting a patient encounter per the 1997 CMS documentation guidelines? For example, the physician states " Patient is alert and oriented x3, in no acute distress, neurovascular status intact, limited ROM w/pain. Patient presents w/R knee pain that started three wks ago that is described as a severe throbbing pain." The physician statement combines both the exam and HPI. Also, can we count exam element mentioned in HPI towards the total required number of exam components required to select an E/M level?

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