ED Coding and Reimbursement Alert

Question: An internal chart audit of our evaluation and management claims showed that our history of present illness (HPI) levels lessened the rightful service level of some claims. Would you offer tips on getting the most accurate HPI level possible for each E/M?


North Dakota Subscriber

Answer: Getting a full picture of a patient's medical history is a difficult challenge, but one you can meet. Check out this review of the elements that go toward determining HPI:

Location is the place on the patient's body where the injury or trauma occurred (e.g., -on the left forearm-).
 
Context is what the patient was doing when the injury or trauma occurred (e.g., -patient had chest pain while climbing stairs-).

Quality represents the chief complaint or sign or symptoms. So if a patient reports with a dull pain in her lower extremities, -dull- is the quality.

Timing is the time of day the patient experienced the signs and symptoms. If the notes say, -Severe depression at night, last two weeks,- -at night- is the timing.

Severity shows just how serious the patient's condition is. Physicians often show severity in their notes with a scale of 1 (least painful) to 10 (most painful).

Duration is how long the patient's signs and symptoms have been present (e.g., -Patient has had severe headache, last four hours-).

Modifying factors are things the patient did himself to alleviate the pain, as well as the things the patient did to make the symptoms worse (e.g., -Patient's chest pain was worsened by his pacing around the room- or -Chest pain improved when patient sat down and breathed deeply-).

Associated signs and symptoms are any other problems the patient has in addition to the chief complaint (e.g., blurred vision might be an associated symptom of a severe headache).