EM Coding Alert

Question: I have a question about history of present illness (HPI) and how it relates to reporting ED-based evaluation and management (E/M) services. I’m auditing a note that states:

“CC: A patient seen in the office complains of left ear pain.

HPI: Patient complains of dull ache in left ear over the past 24 hours.”

Would “dull ache” as in ear pain count as one or two HPI qualifiers? Does the note support brief or extended HPI?

Massachusetts Subscriber

Answer: Dull ache counts as two HPI elements. Ache is the symptom, and dull is the quality of the symptom.

The note includes a total of four HPI elements, which the AMA- and CMS-approved E/M documentation guidelines consider extended HPI. You need at least four HPI elements or the status of at least three chronic or inactive conditions for extended HPI. In addition to quality (dull) and symptom (ache), you have location (left ear) and duration (over past 24 hours).

Of note: Although the CMS documentation guidelines include eight, CPT^® lists only seven, as it does not include “duration” in its list of HPI elements. Either way, four HPI elements are required for an extensive HPI.

The other HPI elements include severity (for instance, pain scale), timing, context, and modifying factors. See if you can spot the additional HPI in this note:

“Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and ibuprofen.” In addition to the same location, quality, ache, and duration elements listed in your note, the second note also indicates:

• Context (went swimming)
• Modifying factors (relieved by warm compress and ibuprofen).