Dermatology Coding Alert

Question: How does a brief history of present illness (HPI) differ from an extended HPI?

Michigan Subscriber

Answer: You can distinguish between brief and extended HPIs based on the detail the dermatologist needs to accurately characterize the clinical problem(s). Specifically, a brief HPI consists of one to three elements, but an extended HPI consists of four or more elements, according to the CMS "1995 Documentation Guidelines for Evaluation & Management Services."

An extended HPI is necessary to reach a detailed history and thus the higher levels of E/M services. For instance, established patient office visit code 99214  requires a detailed history, which requires that the physician perform and document an extended HPI (four or more elements), extended review of systems (ROS) (two or more systems), and a pertinent past, family and/or social history (PFSH) (one of the three).

Documenting only three HPI elements will restrict you to 99213. On the hospital side, a brief HPI of three elements will land you with the lowest-level admission code, 99221 (Initial hospital care, per day, for the  valuation and management of a patient ...).

The HPI is a chronological description of the patient's present illness from the first sign and/or symptom to the present. When counting HPI elements, look for these factors:

• location -- what is the location of the problem?

• quality -- what is the quality of the problem?

• severity -- how intense is the pain?

• duration -- how long has the patient had the problem?

• timing -- is the problem better or worse at any time of the day?

• context -- what is the patient's whole care setting?

• modifying factors -- what can the patient do to alleviate or aggravate the pain?

• associated signs and symptoms -- what other symptoms and signs does the patient have in relation to the chief complaint?

--Technical and coding advice for You Be the Coder and Reader Questions provided by Pamela Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas.