EM Coding Alert

Asking pointed questions will help you sort through HPI.

During the history of present illness (HPI) portion of an E/M service, the first order of business is ascertaining the patient’s chief complaint (CC). From there, you ask about each of the HPI components individually to get a fuller picture of the patient’s condition.

Problem: It might be pretty easy to get a CC from the patient, but how do you continue with the HPI questions after you establish the CC?

Solution: For answers, we turned to Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.

Get More Specific With Queries After CC

After you establish the CC, Swanson recommends continuing the E/M evaluation with these follow-up questions that address each of the HPI components:

1. Location: “Is the symptom located in a specific place? Has this changed over time? If the symptom is not focal, does it radiate to a specific area of the body?” says Swanson.
2. Quality: “When describing pain, ask the patient to further describe the pain, if it’s like anything else that they’ve felt in the past. Knife-like? A sensation of pressure? Aching pain?” Swanson explains. “If it affects their activity level, determine to what degree this occurs. For example, if they complain of shortness of breath [SOB] with walking, how many blocks can they walk? How does this compare with six months ago?”
3. Severity: “How bothersome is this problem? Does it interfere with your daily activities? Does it keep you up at night?” Swanson offers. “If the patient is describing pain, ask them to rate it from 1 to 10 with 10 being the worst pain.”
4. Duration: “How long has this condition lasted? Is it similar to a past problem? If so, what was done at that time?” says Swanson. (Note: Some third-party payers might not consider duration an HPI component.)
5. Timing: Is the problem getting better, worse, or staying the same? If it is changing, what has been the rate of change?
6. Modifying factors: What has made the CC better (or worse)? Rest, eating, etc.?
7. Context: Does this problem occur at a certain time, or in certain situations? Is it better or worse when you do certain things, such as after eating, before bed, etc.?
8. Associated signs and symptoms: Have you experienced any other problems at the same time as the CC? (Nausea/vomiting, pain, headache, etc.) “The patient may notice other things that have come up around the same time as the dominant problem,” explains Swanson. Ask the patient to explain any associated symptoms further, as the issues may be related.

Ask These Extra Questions to Round Out HPI

In addition to the above queries, Swanson recommends that you ask the patient what he thinks the problem is and what he is concerned about. If the issue is chronic, the physician may have a good idea about the patient’s condition; he would just need to ask questions about the problem, mostly focused on how the chronic condition has progressed since the patient’s last E/M.

“This may be particularly relevant when a patient chooses to make mention of symptoms or complaints that appear to be longstanding,” Swanson says. In these instances, it could be beneficial to ask additional HPI questions such as:

• Is there something new/different today as opposed to every other day when this problem has been present? Does this relate to a gradual worsening of the symptom itself? 
• Have you developed a new perception of the problem’s relative importance (for example, a friend told the patient to get it checked out)?