ED Coding and Reimbursement Alert

Question: A 50-year-old female patient reports to the ED complaining of severe abdominal pain; her medical history indicates that she has suffered two past hernias, which were both surgically repaired. The patient says the pain is occurring mostly in her umbilical and upper epigastric areas. Notes indicate that the sharp and nonradiating pains have been occurring "off and on" for two or three days; further the pains are getting worse each day. The notes also read that the pain gets worse when she sits up, but she reports no nausea or vomiting. What level history of present illness is this encounter?

This is an extended HPI, as the physician noted seven HPI elements:

• Location (pain in upper epigastric, umbilical areas)
• Duration (pain has gone on for two or three days)
• Severity (pain gets worse each day)
• Timing (pain occurs "off and on")
• Quality (pain is sharp, non-radiating)
• Modifying factors (pain increases in seated position)
• Associated signs and symptoms (patient experiences no nausea or vomiting).

Breakdown: There are two types of HPI: brief and extended. A brief HPI occurs when the provider lists three or fewer HPI elements; payers consider four or more elements extended HPI.

An extended HPI can support up to a level-five E/M service (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 condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...).

Extended HPI does not, however, guarantee a high-level ED E/M code. Be sure to consider all three components of an ED E/M service when choosing the appropriatelevel code (99281-99285).