ED Coding and Reimbursement Alert

HPI is often misunderstood, but always important.

Last month, ED Coding Alert provided a rundown on coding the review of systems (ROS) elements that you need to identify to submit your ED E/M codes (99281-99285). This month, read on for some tips that will help you ensure your HPI is buttoned up.

Know What HPI Is

Documentation guidelines from the Centers for Medicare & Medicaid Services (CMS) indicate 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 introduces the reason that the patient is seeking treatment.

Unlike the ROS and past, family, and social history (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, condition, or other factor that is the reason for the encounter questions.

Master 8 Magic Bullets

Medicare provides eight specific elements to consider when obtaining the HPI. These elements are:

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

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 providers in this setting usually evaluate acute or current symptoms. An extended HPI is required for reporting 99284 or 99285.

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.

Provider Should Record HPI

At issue in some audits is the topic of 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. The ED physician would document “Hx 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 electronic health records (EHRs), it still occurs in some cases. The physician will either not document an HPI, or will record an abbreviated HPI because they see the nurse’s notes on the screen since the triage history will be imported into the physician’s notes. Only HPI elements obtained and documented by the ED provider can be used for coding.