ED Coding and Reimbursement Alert

Prove extended HPI or settle for 99281, through 99283.

If you don't recognize the difference between brief and extended history of present illness (HPI), you could be costing your EDs hundreds in miscoded E/ M services, as the HPI level often determines the proper ED E/M code choice.

Coders could also overcode HPI level without the proper knowledge, leading to potential audits and rejected claims. Check out this HPI FAQ for some expert input on choosing HPI levels.

What is HPI?

In basic terms, HPI is a "timeline" of the patient's condition -- from the start of the condition/injury to the time of the ED presentation.

"HPI is actually the crux of the medical interview. It is a description of the present illness from its inception to the time of the medical interview," says Martin Herman, M.D., Pediatric Emergency Medicine, Sacred Heart Children's Hospital, Division of Pediatrics, Florida State University at Sacred Heart in Tallahassee.

"If there has been a prior visit for the same problem, then the HPI may involve just the time from the last evaluation to the current encounter," says Herman. "I think of the HPI as those questions any good investigator would want to know to arrive at the diagnosis or solution to a mystery."

Example: A patient presents to the ED with an injured arm he suffered two weeks ago. The HPI is all of the patient information pertaining to that injury so that the physician can craft an informed treatment plan.

"[HPI] serves to identify all of the pertinent facts that are related to a patient's chief complaint. It questions how did the problem develop and what events are related? It also may inquire about how the patient has reacted to the problem," says Kenneth Engel, CPC, CHC, ACSEM, CCP, chief compliance officer with Martin Gottlieb Associates in Jacksonville, Fla.

HPI clues: In encounter notes, Engel says you might find answers to the following HPI questions:

• Where is the problem?
• How bad is it?
• When did you first experience it?
• How long does it last?
• What's it like?
• What relieves it or makes it worse?
• In what setting did it occur?
• Are there any other related problems?

How Do You Determine HPI?

There are two levels of HPI, for coding purposes: brief and extended. Without knowing the HPI level, it is impossible to be certain of your E/M coding.

Why? Brief HPI will only support a lower-level ED E/M service, confirms Christina Myruski, Operations Manager at Medicom Management Services, Inc., in New Windsor, N.Y. If the HPI is brief, you cannot code an ED E/M service higher than 99283, she says.

To determine the HPI level, you'll need to know the elements of HPI. "As a guide to the provider when trying to delineate the nature of the illness, CPT has defined specific elements to consider when interrogating the patient," says Herman. These elements are:

• location,
• quality,
• severity,
• timing,
• context,
• modifying factors,
• associated signs and symptoms (Note: Medicare adds an 8th potential HPI element of duration)

In order to arrive at the proper HPI level, you'll need to know how many of these elements your physician addressed during the patient interview. By definition, a brief HPI consists of one to three elements and an extended HPI has four elements or more.

"Usually a brief HPI is focusing just on the problem at presentation; it may include other minor symptoms associated," Myruski says. Depending on other areas of documentation, you'd choose a code from 99281 through 99283 for brief HPI patients.

If the physician performs an extended HPI, however, you might be able to report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...) or 99285, depending on other areas of documentation for the patient encounter.

How Do HPI Levels Differ Clinically?

For greater illustration of HPI levels, check out this pair of examples, each illustrating a different HPI level:

Example 1 (Courtesy of Herman): A 2-year-old is brought to the ED by her mother with an insect bite on  her face. The physician examines the patient's immediate bite area, and asks the mother how long the bite has been present. The mother says that the child was bit on her upper eyelid about 24 hours ago. The physician discharges the patient with topical ointment. Notes from the rest of the encounter indicate expanded problem focused history and exam, along with low-complexity medical decision making.

"This is a brief HPI; the elements are duration and location," says Herman.

On the claim, you'd report 99281 or 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: ...) for this encounter, depending on other specifics from the visit.

Example 2 (Courtesy of Engel): A 26-year-old female patient reports to the ED with a chief complaint of right sided (LOCATION) abdominal pain. Her symptoms have been going on for about a week and a half [DURATION]. Initially, it was just dull aching discomfort [QUALITY] in her right sided abdomen [LOCATION]. This discomfort has remained but is worse in the morning, [TIMING].

The patient reports she saw her physician seven days ago, had a urinalysis and was diagnosed with a urinary tract infection that she was treating with Cipro, which she finished yesterday [CONTEXT]. While taking the Cipro, the patient says the pain started to abate [MODIFYING FACTOR]. However, a couple of days ag,o she developed some head cold symptoms as well as a cough and now has a low-grade fever, aswell as soreness in her left axilla and left flank area [ASSOCIATED SIGNS AND SYMPTOMS]. Earlier in the day, the patient reported to an urgent care center and had a temperature of 103 degrees. The urgent care provider sent the patient to the ED for further treatment. Documentation from the rest of the encounter indicates detailed history and exam, along with moderate MDM.

This is an extended HPI scenario, Engel says. On the claim, report 99284 for this E/M service.