Coding Guidelines, E/M Coding

Quick Guide: Elements of HPI For E/M Coding

Okay, I’m the first to admit that I don’t like coding E/M. When I was first starting out and looking for coding jobs, I would do my best to avoid applying for anything that had any E/M mentioned in the job description. I ultimately lucked out, and got into radiology coding, which I love. Then later when I moved on…guess what my first assignment was–doing an E/M audit! I was lucky (again) that I had wonderful coworkers to help me along the way. But I do distinctively remember crying over it one day while working on it. It just wasn’t my thing. But over time, that has changed (a little bit) and now I  can do an E/M audit with less problems (and less crying). But it still is confusing and every time I work on anything E/M, I have to review everything to refresh my memory.

One part that I think can be a little confusing is going over the HPI and counting up the elements. In theory, you would think this would be the easy part. Maybe it is for some people, but not for me. So I review this and it helps, so I thought I’d share it here. This comes directly from the CMS website:

History of Present Illness (HPI) HPI is a chronological description of the development of the patients’ present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:


  • Location (example: left leg)


  • Quality (example: aching, burning, radiating pain)


  • Severity (example: 10 on a scale of 1 to 10)


  • Duration (example: started 3 days ago)


  • Timing (example: constant or comes and goes)


  • Context (example: lifted large object at work)


  • Modifying factors (example: better when heat is applied)


  • Associated signs and symptoms (example: numbness in toes)



So, that’s it! Does this list at least help a little bit? I could attempt to go on and on about E/M and try to explain it in more detail, but I don’t want to confuse anyone even more. I feel like E/M is something that can only be learned by coding practice cases or just learned over time. I will share the audit sheet I use though. It is from Novitas and you can find it here. Please note though–this is the 1995 guidelines.

If you’re looking for the 1997 guidelines/specialty exam score sheets, go here.

These are by no means the only score sheets available. This is just what I personally use, so I thought I would share it on the blog.


Thanks for reading,



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