Dermatology Coding Alert

How many of the essential 8 questions did your physician document?

If you're like many dermatology coders, you sometimes have trouble understanding the elements of history of present illness (HPI) and why it's important to count them. Here's your quick run-down of why -- and how--to correctly count HPI elements, plus examples straight from a dermatology coder's desk.

You need to count HPI elements because they're an important part of the history component of E/M services. A brief HPI consists of one to three elements, whereas an extended HPI requires four or more elements.

Your dermatologist must perform an extended HPI in order to satisfy the requirements for a detailed or comprehensive history. Reaching an extended HPI does not guarantee that you can report a high-level E/M code --your physician must still satisfy the other elements of the service before you choose a high-level code. Having the extended HPI is one step toward that possibility For coding purposes, HPI is an ordered description of the patient's current malady.

"Dermatology HPIs can be a little more challenging than with some other specialties, in that there are not always problems," says Sandy Adams-Stevens, a coding/documentation specialist with Heritage Medical Associates in Nashville, Tenn. "Some patients have problems, but some are only there for a 'skin check.' Of course, if they don't really have a problem, it means it may not be possible to support a higher-level E/M code."

Checklist: When counting elements, see how many of these eight questions your physician answers in the notes:

1. What is the physical location of the problem on or in the body? (location)

2. How is the symptom further described related to the type of pain (such as itchy or burning)? (quality)

3. How intense is the problem or related pain? (severity)

4. How long has the patient had the problem? (duration)

5. Is the problem better or worse at any time of the day? (timing)

6. How did the injury occur? (context)

7. What can the patient do to alleviate or aggravate the pain? (modifying factors)

8. What other symptoms and signs does the patient have in relation to the chief complaint? (associated signs and symptoms)

Note: CPT does not include duration in its list of HPI elements, so it has seven elements.

With two sets of E/M guidelines to choose between (1995 and 1997), ensuring your documentation stays on track can be tricky for anyone. You have other things to keep in mind, however, when you deal with dermatology.

"The standard exam established for dermatology includes only three organs/systems, based on the 1995 guidelines--constitutional, ENT, and skin," Adams- Stevens says. "However, you have 16 bullets within those organs/systems, based on the 1997 guidelines. My advice to our dermatologists has been to reach the level of exam by examining elements within the system(s); that is, they count bullets from 1997 instead of organs/areas in the 1995 guidelines."

Higher level tip: The integumentary system guidelines include only 12 recognized bullets (including eccrine/apocrine glands, which Adams-Stevens says are rarely examined). You have a total of 16 bullets recognized within the three dermatology organs/systems, however, so your provider only needs to examine two more bullets/elements for a total of 18 to qualify for comprehensive exam coding.

Caution: Although the math might work that way, Stevens-Adams stresses that she's not suggesting that providers gather more history than needed or examine more than medically necessary. "I'm only explaining documentation guidelines," she says. "The well-being and clinical outcome of our patients are the utmost concern, no matter the documentation. The amount of history and exam should be commensurate with the nature of the problem and overall risk, which means it might not always be possible to support higher levels of E/M codes."

"I have a personal belief that once you hit four, you stop," adds Pamela J. Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education, Inc., in Watauga, Tex. "You hit the maximum for coding and identifying more is not time-efficient."

Put the Pieces Together

Reading a list of criteria is one thing; seeing how they might come together in a case is another. Test yourself by coding the following scenarios.

Example 1: Problem-oriented visit CC: Spot on back

HPI: Pt presents today for a spot on his back (location); his wife just noticed it, so they're unsure how long it's been there (duration). He says he's not out in the sun much, and when he is, he doesn't [or does] use sun block (modifying factors); he denies that it bothers him in any way, e.g., with clothing (sign/symptoms).

ROS: (Skin) denies itching; (Allergy/Immunologic) denies allergic or immunologic issues.

PFSH: No family history of skin cancer.

Example 2: Skin check with no known problem CC: Skin check

HPI: Pt presents today for a skin check, without any complaints. She has not noticed any spots on any part of her body, nor does she have any issues that particularly concern her (location). She has Fitzpatrick skin type V; tans very easily (modifying factors).

ROS: (Skin) denies problems; (Allergy/Immunologic) denies allergic or immunologic issues.

PFSH: No family history of skin cancer.Once you determine your answers, turn to page 14 to see what our experts recommend.