Gastroenterology Coding Alert

Resolve CPT®/Medicare conflicts when counting HPI elements.

You could be losing out on reporting potential level 4 or 5 E/M visits if you’re not vigilant about the history of present illness (HPI) documented by your gastroenterologist. Take tips from this guide on accurately capturing HPI elements so that you don’t miss out on higher-reimbursement opportunities. 

HPI Elements Decoded 

HPI is one of the three components of an outpatient E/M history. It describes the patient’s present illness or problem, from the first sign/symptom to the current status, and typically decides your gastroenterologist’s course of actions about the physical examination and treatment.

The information you capture during the physical exam (PE) portion of a patient’s evaluation usually only shows a very limited picture of the patient’s problem. However, speaking with a patient and gathering the history of the patient’s problem can relate the entire picture. Therefore, the HPI often times is the most important aspect of a patient’s evaluation.

Start counting: HPI will also often determine the level of service you’ll report. You’ll count the HPI elements to help you determine which level of service you can report. There are seven or eight HPI elements, depending on which system you follow. Medicare recognizes eight elements:

• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associated signs and symptoms.

CPT® only requires seven HPI elements, with “duration” out of the list. Therefore, for Medicare payers, you should consider duration and timing separately. With payers that follow CPT®, however, be aware of this distinction.

Double Check Your Physician’s Documentation

HPI can be categorized into two types: brief and extended. If your gastroenterologist documents one to three HPI elements, then it is classified as a brief HPI.

When you have a brief HPI you won’t be able to code any higher than a level two new patient E/M (99202, Office or other outpatient visit for the evaluation and management of a new patient ...), regardless of the encounter’s other specifics.

For an established patient, a brief HPI can support up to and includes 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

On the other hand, when your gastroenterologist documents four or more HPI elements, you have an extended HPI. Your physician must achieve an extended HPI to document at least a detailed history. An extended HPI is a requirement for 99203-99205 (New patients) and 99214-99215 (Established patients).

Scenario: A brief HPI might be appropriate for a follow-up for a mild infection that has responded to treatment. However, an extended HPI would include (especially if the patient is doing poorly) the length of time the current problem has been going on, what seems to make the problem better or worse, if it is worse during a particular portion of the day, the severity, and if the patient has any other signs/symptoms.

Note: An extended HPI does not automatically ensure a higher-level E/M code, but it does make reporting it possible. Ensure your gastroenterologist has met the other required elements of service before choosing these high-level codes. Make sure your doctors obtain and document as much information as possible to allow billing a higher level E/M.

Accurate Documentation is Key

The key point is that the gastroenterologist himself must obtain the HPI. He cannot just use or report the information obtained by his staff. The physician must personally obtain, refine, add to, complete, and document the HPI if he expects to receive credit and reimbursement for his services. Any employee in your practice, or even the patient himself, can document part of the history. In fact, the E/M service documentation guidelines state that ancillary staff may obtain and record the review of systems (ROS) and/or past family social history (PFSH). The physician must review both the ROS and PFSH, sign both as an indication of his review, and indicate any additions he personally documented, however.

Caution: The physician, or other licensed provider, needs to reference the information provided. Since the HPI should be the driving force behind the type of evaluation provided to a patient and treatment options, the HPI most definitely should only be documented by the physician.