ED Coding and Reimbursement Alert

Properly counting the history of present illness (HPI) elements your ED physician addresses can make a world of difference in your E/M coding, as certain E/Ms are typically not possible without high-level HPI.

Coders should consider HPI a "description of the development of the patient's present illness, from the first sign or symptom to the present," explains Tracey Koch, CCS-P, ER client support coding and education manager at Comprehensive Medical Management in Newport, Ky. "HPI is the most important part of patient assessment. When you have a good history, 90 percent of the time the physician can identify what is wrong with the patient; he'll then spend the other 10 percent confirming what he learned in the history," says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC.

Example: A patient reports that she has urinary frequency and burning when urinating. During the HPI, the physician discovers that the patient also started passing blood two days ago. This leads the physician to check the patient for a urinary tract infection (UTI), which he confirms after a level-three E/M (99283).

This is a good example of HPI driving treatment options, a time Gilhooly says the provider asks herself: "What do I have to do during the exam and what kinds of tests will I have to do based on this information?" ED Coding Alert/2009, Vol. 12, No. 12 Get CPC® certified in 4 days -- CodingCert.com Page 91

There are seven or eight HPI elements, depending on which source you are citing. In Medicare, the eight elements are:

• location

• quality

• severity

• duration

• timing

• context

• modifying factors

• associated signs and symptoms.

CPT only lists seven HPI elements, however; duration did not make CPT's list.

Best bet: For Medicare payers, continue to consider duration and timing separately. With payers that follow CPT, however, be aware of this distinction.

There are two different types of HPI: brief and extended. If the ED physician performs a brief HPI, she documents between one and three elements. Brief HPI supports no higher than 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...), regardless of the encounter's other specifics.

For extended HPI, "payers are going to expect more than three [HPI] elements," explains Gilhooly. Extended HPI can support up to 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) -- though extended HPI does not guarantee level-four or -five service.

Example: Consider this history note, which addresses five HPI elements and qualifies as extended HPI. "Patient comes in today with right-sided abd pain (location). Patient states pain has been present for 3 days (duration) and rates pain as 5 on 10 scale (severity). The patient denies nausea or vomiting (associated signs and symptoms), says pain is worst right after she wakes (timing)."