EM Coding Alert

Remember the eight components of HPI when you’re looking at documentation.

Since the evaluation and management (E/M) updates occurred in 2021 and 2023, the focus on E/M education has shifted from discussing each documentation component to mainly medical decision making (MDM). While MDM is important and is what we used to determine a level of service, the history and exam components are just as important when telling the patient’s story.

Keep reading to find out more about the significance of the history of present illness (HPI) and chief complaint (CC) components.

Understand Chief Complaint

The CC sets the tone and purpose of the visit and is usually listed above the HPI section of the note. The reason for the visit can be a multitude of issues, like preventive check-up/screening, new or established problem, or follow-up care.

One of the main issues that we see in the chief complaint is that it is too vague. For example, “Patient presents for follow-up.” A coder’s first question may be: “What is the patient following up on?” While the rest of the note should answer that question, this statement isn’t always helpful when used because it doesn’t show whether a patient is established, whether the problem is new or acute, or whether there will be multiple conditions listed in the CC, especially if they are not all addressed in the body of the note.

Here are some best practice CC examples:

• “Chief Complaint: Patient presents for follow-up on bilateral acute otitis media.”
• “Chief Complaint: Patient presents for insulin dependent uncontrolled type 2 diabetes with hyperglycemia follow-up.”
• “Chief Complaint: AWV and medication refill.”

As you can see, the chief complaint is like the title of the patient’s story for that visit.

Check Out These Aspects of History of Present Illness (HPI)

The HPI gives us insight into why the patient is being seen and what led up to the reason for the visit.

There are a total of eight HPI components that can be documented:

• Location: The location is where the problem exists. For example, right upper quadrant pain, lesion on the left cheek, or right great toe fungal infection.
• Quality: The patient’s verbiage when describing the characteristics of the problem. For example, throbbing pain, yellow/green mucus, or dry cough.
• Severity: The patient’s way of measuring how “bad” the problem is. For example, a pain scale of 1-10, better or worsening, intolerable pain, or unable to walk to the next room without losing their breath.
• Duration: How long the patient has been experiencing the problem. For example, a few hours, couple weeks, or five years.
• Timing: When the problem happens. For example, migraine after eating chocolate, nighttime bedwetting, intermittent or constant.
• Context: What could have caused the problem. For example, back pain after lifting a heavy object, left hip arthritis after a motor vehicle accident (MVA), or during an argument with their spouse.
• Modifying factors: Anything the patient has tried to help the problem or that makes it worse. For example, heat and ice, over-the-counter (OTC) medications, or seeing another provider.
• Associated signs and symptoms: Additional symptoms the patient is experiencing that coexist with the primary complaint. For example, a patient is being seen for hypertension and also complains of dizziness, heart palpitations, and headaches.

If you have current or former nurse practitioner students, OLDCARTS is the mnemonic device they will remember. Here’s what the letters represent:

• Onset (Context)
• Location
• Duration
• Character (Quality)
• Aggravating factors (Associated signs and symptoms)
• Relieving factors (Modifying factors)
• Timing
• Severity

Check Out This Example

Here’s what the HPI might look like for a patient who has symptoms resembling an acute respiratory infection:

Annie is a 58-year-old female who presents with sore throat, phlegm (yellow-green in color), runny nose, and headache that started about a week ago. She noticed symptoms after visiting her grandson, who had a cold at the time. Her symptoms bother her all day, but notices her drainage is worse in the morning after waking up; suspects this is from lying down flat and not “up and moving around.” She has tried Mucinex, throat spray, and humidifier with some improvement. She also has uncontrolled type 2 diabetes with hyperglycemia, and asked us to avoid steroids because it made her blood sugars worse than usual.

When you’re looking at HPI, look for the eight components listed above.

As an exercise, it may be helpful to think about the patients that your practice sees and determine whether any conditions are common, and what information may be left out of the HPI your physicians are taking.

Kaitlyn Brack, CPC, CPMS, CEMC, CFPC, CPEDC, Approved Instructor, Medical Coding Auditor and Educator, Baptist Health Deaconess, Madisonville, Kentucky