Gastroenterology Coding Alert

Hint: Can SOCRATES help shore up your E/M claims?

As most coders know, a history of present illness (HPI) is a key part of your E/M documentation. Unfortunately, however, myths persist about how you should document this critical element. Read on for four myths about HPI-along with expert tips that bring you back to reality.

What's Your HPI IQ?

HPI is an element within the history component - one of the three key factors used in selecting the correct level of E/M service. The CPT® manual defines HPI as "a chronological description of the development of the patient's present illness from the first sign and/or symptom to the present" and goes on to identify eight individual HPI elements.

Fun fact: You can remember those elements using the mnemonic SOCRATES.

• Site (Location): The anatomical place or site of the chief complaint.
• Onset (Duration): Length of time of the complaint.
• Context: The circumstances/environment in which the symptoms occur.
• Radiation (Quality): How the complaint feels (stabbing, achy, itchy, better, worse, etc.).
• Associated signs and symptoms: Other related factors or symptoms, positive or negative.
• Timing: How often the symptoms occur (frequently, occasionally, etc.).
• Exacerbating/Alleviating (Modifying factors): Anything that relieves or aggravates the problem.
• Severity: The degree of intensity of the signs or symptoms (1-10 pain scale, wincing, doubled over in pain, etc.).

There are two levels of HPI - brief and extended. Per both the 1995 and 1997 guidelines, you tally HPI by reviewing the notes and deciding how many of the above eight elements the provider has reviewed relative to the patient's chief complaint (CC).

For a brief, problem-focused, or expanded problem-focused HPI the documentation needs to include one to three of the above elements.

For an extended, detailed, or comprehensive HPI the documentation needs to include four or more of the above elements.

Myth 1: Just Listing the HPI Conditions Is Sufficient

Not so, says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. "Just listing is not enough. Your provider needs to document the status of each condition for the condition to count."

Myth 2: Duration Is not Regarded as an HPI Element

Although the CPT^® guidelines state that HPI should include "a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms," without mention of duration, that's not the case with Medicare.

As Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana points out, the confusion over this issue arises because "the Centers for Medicare and Medicaid Services (CMS) does recognize duration as an element of HPI. Most auditors," Holle goes on to say, "go by CMS in regard to HPI because they are the highest guideline out there, and most carriers follow the guidelines put out by CMS."

Remember: If you are unsure of a payer's HPI element list, call your representative to check and then document the response.

Myth 3: You Can't Document Non-HPI Elements for HPI

Actually, this is permissible, providing it is done in the right way. Falbo offers the following example: "If, during the review of systems (ROS) portion of the exam, the provider documents 'shortness of breath with chest pain,'" Falbo explains, "it would be appropriate to credit 'shortness of breath' in the ROS documentation and as a sign and symptom for the HPI."

Holle agrees, adding that this can be a source of great coding confusion. "Stating a cough is in the lungs is not specifying location," Holle says, "but stating having chest pain under the ribs when coughing would be location."

Once again, however, Falbo cautions that individual payers' guidelines may differ, so it would be a good idea to seek clarification from them first about their ruling.

Myth 4: You Can Document Chronic Conditions Instead of HPI

This is where the 1995 and 1997 guidelines get muddied. If you are using the 1995 guidelines, documenting chronic conditions is not acceptable. Under 1997 guidelines, however, you can use 1-2 chronic medical problems instead of 1-3 HPI elements for a brief problem-focused or expanded problem-focused HPI, and 3 chronic medical problems instead of 4 HPI elements for an extended, detailed, compre­hensive HPI. But whichever set of guidelines you use, make sure you use one or the other, not both, except for the specific instance of using the status of "three or more chronic conditions (1997) in a note that otherwise follows 1995 guidelines for the details of a physical exam.

As CMS states in its MLN document entitled Evaluation and Management Services, "For reporting services furnished on and after September 10, 2013, to Medicare, you may use the 1997 documentation guidelines for an extended HPI along with other elements from the 1995 documentation guidelines to document an E/M service."

The golden rule? Holle offers this important piece of advice for coders: "your provider HAS to obtain this portion of the history. In many offices," Holle continues, "the clinical staff will list the chief complaint and maybe even a couple statements. However, the provider will need to perform and document the HPI portion of the service for it to count in an audit."

What Does the Future Hold for HPI and E/M Guidelines?

In its most recent annual revision of the Medicare physician fee schedule (PFS), CMS has once again hinted that the guidelines for E/M documentation are due for a major overhaul. They agree with stakeholders that such a revision "could both reduce clinical burden and improve documentation in a way that would be more effective in clinical workflows and care coordination."

But don't hold your breath expecting that the change will happen any time soon. CMS goes on to say that such "a comprehensive reform of E/M documentation guidelines would require a multiyear, collaborative effort among stakeholders."