Anesthesia Coding Alert

Watch these 8 areas to paint a clear picture of the patient's situation

Understanding each patient's history of present illness (HPI) is an integral part of your E/M coding. If your internal -- or external -- audits show that you're missing the mark when coding E/M service levels, brush up on these eight areas that contribute to determining HPI:

1. Location is the place on the patient's body where the symptoms exist ("the lower back," for instance).

2. Context is what the patient was doing when the problem occurred (such as "patient had lower back pain after standing on his feet at work all day").

3. Quality represents the chief complaint or signs or symptoms. So if a patient reports with a sharp pain in her shoulder, "sharp" is the quality.

4. Timing is the time of day the patient experienced the signs and symptoms. If the notes say, "Pain after standing for long periods, last two weeks," "after standing for long periods" is the timing.

5. Severity shows just how serious the patient's condition is. Physicians often show severity in their notes with a scale of 1 (least painful) to 10 (most painful).

6. Duration is how long the patient's signs and symptoms have been present (for instance, "Patient has had sharp/severe shoulder pain, last three weeks"). "Last three weeks" is the duration of the condition.

7. Modifying factors are things the patient did herself to alleviate the pain, as well as the things the patient did to make the symptoms worse (for example, "Patient's low back pain was worsened by continuing to stand for long periods" or "Pain improved when patient sat for 15-20 minutes").

8. Associated signs and symptoms are any other problems the patient has in addition to the chief complaint (for example, blurred vision might be an associated symptom of a migraine).

For most upper-level E/M codes, the pain management specialist's HPI documentation must cover a minimum of four of these points.

"Once you get to four, you can stop counting because the highest level is an extended HPI, which is four or more elements," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher.

At the same time, your physician should only cover HPI elements that are relevant to the chief complaint and to the level of medical decision-making. In other words, your pain management specialist should not list HPI elements that are not relevant just to increase the HPI level. If the patient's condition only meets straightforward medical decision-making, listing an answer to each HPI element may not be relevant.