EM Coding Alert

Make your provider’s job easier by providing a list of questions to cover.

In “Differentiating Brief vs. Extended HPI Will Pave the Way to 99204/5 and 99214/5 Success,” you learned how to use history of present illness (HPI) to determine the E/M level reportable for your provider’s services. Now, take a look at this checklist to help determine the HPI level a service meets. When counting elements of HPI, check to see how many of these eight questions your provider answers in the notes:

·         What is the location of the problem? (location of pain, mass, or organ involved)

·         What is the quality of the problem? (nature of the pain, such as dull or colicky)

·         How intense is the pain or problem? (severity)

·         How long has the patient had the problem? (duration)

·         Is the problem better or worse at any time of the day? (timing)

·         What is the setting or circumstances in which the problem occurs? (context)

·         What can the patient do to alleviate or aggravate the problem? (modifying factors)

·         What other symptoms and signs does the patient have in relation to the chief complaint? (associated signs and symptoms)

Note: Payers that follow CPT^® guidelines won’t accept duration as an HPI element, so don’t include it in your HPI count for those claims. See the article on page 11 for more information about CPT^® and Medicare HPI differences.