ED Coding and Reimbursement Alert

Use the right terms to master this important E/M component which is a frequent audit target. 

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: We know from the 1995 CMS documentation guidelines that the HPI is a chronological description of the development of the patient’s present illness from the first sign or symptom to the present encounter. It can be an expansion on the chief complaint and really introduces the reason that the patient is seeking treatment.  

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 the Seven HPI Bullets

CPT® has defined seven specific elements to consider when obtaining the HPI. These elements are: 

• Location
• Quality
• Severity
• Timing
• Context
• Modifying Factors
• Associated Signs and Symptoms

Or is it Eight? Medicare adds “duration” as an eighth potential HPI element that is not contained in the CPT® book. I’ve never heard of a non-Medicare payer who discounted duration as an acceptable HPI element, adds Thomas.

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 about what each HPI element means, but there is still some confusion over precisely what those elements mean and how similar concepts, such as quality and severity, differ. 

Is The HPI Brief or Extended? Count The Elements to Decide

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, says Thomas.

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.  An extended HPI is required for reporting 99284 or 99285, he adds.

HPI “extended” example: The patient presents complaining of a headache that started yesterday [Duration] after being exposed to exhaust fumes [Context].  He reports nausea but no vomiting [Associated signs and symptoms] and photophobia off and on [Timing].  He describes it as a radiating [Quality] pain over his left eye [Location] he describes as an 8 out of 10 [Severity]. Tylenol has only helped dull the pain a little [Modifying Factor].

Note that all eight HPI elements were present in only four sentences, says Thomas. 

Know the Rules Before Double Counting The Same Documentation For HPI and ROS

 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 CMS 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.” 

Resource: To read a series of letters documenting this policy, see the ACEP website at http://www.acep.org/content.aspx?id=32168&list=1&fid=912

Major issue: Another HPI audit issue is whether the reporting provider personally documented the HPI. 

Be sure that the HPI was recorded by the physician rather than by ancillary staff. This used to be a big problem when ED charts were completely handwritten, says Thomas.  The ED physician would document “History as above” when the triage nurse had described the patient’s presentation.  With dictations and paper templates, this became less of a problem, but with the transition to EMRs, it has reared its head again, Thomas says.  The physician will either not document an HPI or an abbreviated HPI because they see the nurse’s notes on the screen or some EMRs will import the triage history into the physician’s notes.  

Bottom line: Only HPI elements obtained and documented by the ED physician can be used for coding, says Thomas.