General Surgery Coding Alert

Get your physician to collect the information you need, with this handy list.

In the previous article, you learned how to use history of present illness (HPI) to determine the E/M level reportable for your surgeon's services. Now, take a look at this checklist to help determine the HPI level a service meets.

When counting elements of HPI, check to see how many of these eight questions your urologist answers in the notes:

1. What is the location of the problem? (location of pain, mass, or organ involved)

2. What is the quality of the problem? (nature of the pain, such as dull or colicky)

3. How intense is the pain or problem? (severity)

4. How long has the patient had the problem? (duration)

5. Is the problem better or worse at any time of the day? (timing)

6. What is the setting or circumstances in which the problem occurs? (context)

7. What can the patient do to alleviate or aggravate the problem? (modifying factors)

8. What other symptoms and signs does the patient have in relation to the chief complaint? (associated signs and symptoms)

Note: Payers that follow CPT guidelines won't accept duration as an HPI element, so don't include it in your HPI count for those claims. See "Scope Out Potential Level 4 and 5 E/Ms By Knowing Crucial HPI Facts" on page 51 for more information about CPT and Medicare HPI differences.