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 pediatrician 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 three).
 
For follow-up visits, 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 evaluation 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?