Todd Thomas CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK offers the following clarifications of what each HPI element means:
Location is often an anatomic descriptor. It can be as basic as left ankle, distal radius or epigastric pain, or more descriptive such as diffuse or localized to a specific area, unilateral or bilateral. It can even be a written description of where the patient points when asked, “Where does it hurt?”
Best practice: Educate your physicians about documenting specific locations for complaints that seem to include a location, Thomas advises. Complaints like chest pain, headache and abdominal will stand up to an auditor’s scrutiny better with the addition of statement like “substernal” chest pain, “frontal” headache and “LLQ” abdominal pain.
Quality is the characteristic of the symptom such as sharp, pounding, constant or intermittent. Acute, chronic, stable or worsening are also frequently used quality terms.
Severity is a description of the amount of discomfort of a sensation or pain. In the ED, it is usually expressed on a scale of 1 to 10, or compared to some previously experience pain such as childbirth or passing a kidney stone. Sometimes it is expressed as the worst pain of my life, or simply mild, moderate, or severe.
Timing is a pattern of recurrence of the symptom.
Best practice: Look for words like “continuous”, “off and on”, or “when I first get up in the morning.”
Duration is the length of time since the onset of the injury. It is usually expressed in hours or days, but can be a statement along the lines of “since last night.”
Best practice: It can be frustrating for coders to have two or more duration statements in a chart with no timing documentation, but resist the urge to count one of those duration statements as timing, Thomas says.
Context refers to what the patient may have been doing or where they were when the symptoms began. The patient may say, “I’m short of breath after climbing the stairs,” or “my knee hurts after I slipped on the ice.”
Best practice: The emergency physician may ask context questions such as whether the symptom recurs with a specific activity or whether situational stress was present at the time.
Modifying Factors relate to actions that may change, relieve or exacerbate the patient’s symptoms.
Best practice: Look for details on steps that the patient may have taken to obtain relief from their symptoms before seeking care is the most common modifying factor. An example would be treatment, such as taking Ibuprofen or applying ice packs. It can also relate to whether eating or rest changes the condition, Thomas notes.
Associated Signs and Symptoms are either offered by the patient or prompted by the physician’s questions about additional symptoms that may be present when the chief complaint occurs.
Best practice: Look for statements like blurred vision with the headache or diaphoresis associated with indigestion and chest pain. Associated signs and symptoms can also be negative, such as “denies shortness of breath” or “has not experienced any nausea.”
While the CPT® Assistant® article did indicate counting negative findings was acceptable for AS&S, many auditors have been reluctant to allow counting negatives for the other elements, Thomas says. For example, has not taken any ibuprofen (negative Modifying Factor) or no known trauma (negative Context).
Bottom line: Even with these clarifications, it can sometimes be difficult to determine if a HPI element is really context or a modifying factor. There are often terms that could be considered as more than one HPI element, but you can only count the same documented symptom once per chart, warns Thomas.
