Get the story straight on this often misunderstood but very important E/M component. If History of Present Illness (HPI) was the first component of E/M coding you learned, you could be overdue a refresher. Often, it's HPI that trips up ED coders in audits and is the one of the biggest reason for down-coded claims. Read on for a return to fundamentals for capturing the HPI. Get specific Unlike the ROS and PFSH elements of a history, the HPI must be documented by the reporting provider. Additionally, there should be documentation of a chief complaint, which is often a recap of the patient's own words describing the symptom problem or condition or other factor that is the reason for the encounter questions, says Todd Thomas CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK. Master 7 Magic Bullets CPT® has defined seven specific elements to consider when obtaining the HPI. These elements are: Note this: That's all the documentation guidelines say about the elements, just the list, says Thomas. "The CPT Assistant® published a piece back in April 1996 that gave some clarity, but there is still some confusion over precisely what those elements mean and how similar concepts, such as quality and severity, differ." Count Elements to Determine "Brief," "Extended" Once you have identified the documented elements of HPI, you have to know how to apply them toward your eventual level of history and ultimately to the E/M code reported. A brief HPI consists of one to three elements. A brief HPI supports ED E/M codes 99281, 99282, or 99283. An extended HPI is four or more elements. And while the documentation guidelines allow the description of the status of three or more chronic conditions in place of the HPI elements, it is rare that this method would apply in the ED since we usually evaluate acute or current symptoms, says Thomas. An extended HPI is required for reporting 99284 or 99285. HPI "extended" example: Note that all eight HPI elements were present in only four sentences. Pulling Double Duty With HPI and ROS? Watch Out! In audits, one frequent point of contention is counting the same documentation in both the HPI and the ROS areas of the history, Thomas warns. He references a statement from former HCFA official, Dr. Bart McCann from April 1999: "You ask if a single statement may be used in the history of present illness and still be counted in the review of systems without actually being written twice, i.e., in both areas...We agree...that it is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirement for the ROS. There are a series of letters documenting this policy on the ACEP website at http://www.acep.org/content.aspx?id=32168&list=1&fid=912 Major issue: