Need help with clarification of HPI elements. I am not an auditor but the physician has asked me to review some of his charting on E/M codes to make sure the correct level has been billed.

CC: Psoriasis f/u
HPI: 1) scalp, ears 2) + improvement 3) few new spots 4) no problems with current treatment 5) treating w/ T-Gel, T-Sal shampoo, clobetasol solution, and
protopic oint. on face & body

Which elements would you check off for this HPI? I would think Location (scalp, ears) and Modifying Factors (shampoo and prescriptions)

I am unsure if ‘+ improvement’ would be part of modifying factors as the tx is what is causing improvement, or if this would be quality as the quality of the psoriasis has improved. — Lastly, would ‘no problems with current treatment’ be an element of HPI at all, if so, which element?