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ED Coding and Reimbursement Alert

Reader Questions:

Spot Extended HPI for Higher-Level E/Ms

Published on Wed Apr 20, 2011

Question:

A teenager presents with intermittent right sided abdominal pain occurring at least three times per day mostly in the morning for the last week with associated nausea and vomiting. Both parents of the teenager have had their appendixes removed. The patient rates the current pain as eight out of 10, and says it is a sharp, stabbing pain unrelieved by Tylenol. The ED physician performs a physical examination, including a detailed examination of the gastrointestinal system and other related systems including, constitutional, cardiovascular, respiratory, and genitourinary. The physician cannot determine the etiology of the abdominal pain, so the patient is sent for stat labs and a computed tomography (CT) scan of the abdomen. The patient is then asked to follow up the next afternoon for the results. What level of history of present illness (HPI) is this?

North Dakota Subscriber

Answer:

Your physician performed an extended HPI, as he addressed all of the elements of HPI.

Breakdown: There are two levels of HPI: brief and extended. During a brief HPI, the provider inquires about one to three "elements" during the patient encounter. If the provider asks about four or more elements during the encounter, the HPI is considered extended.

This is important for coding purposes, as it is impossible 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 (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 ...) unless the provider performs extended HPI.

Depending on the insurer, there are seven or eight HPI elements; Medicare counts eight HPI elements:

location

quality

severity

duration

timing

context

modifying factors

associated signs and symptoms.

CPT®, however, counts seven HPI elements; duration is not a separate HPI element for insurers that follow CPT® conventions.

No worries: Your claim evidences that the physician addressed all of the HPI elements on either list, which qualifies for an extended HPI regardless of insurer.

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