General Surgery Coding Alert

Watch out for CPT/Medicare differences when counting HPI elements.

If you're not accurately accounting for the history of present illness (HPI) documented by your general surgeon, you could be missing out on opportunities to report level 4 or 5 E/M visits. Ensure you're not missing higher-pay possibilities by reviewing this guide to capturing HPI elements.

Brush Up on What Qualifies as an HPI Element

HPI is one of the three parts comprising 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 drives your surgeon's decisions about the physical examination and treatment.

"The information gathered during the physical exam (PE) portion of a patient's evaluation often 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," explains Amanda S. Stoltman, CCSP, compliance coder in Muncie, Ind. "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 source you are citing. In Medicare, the eight elements are:

• location
• quality
• severity
• duration
• timing
• context
• modifying factors
• associated signs and symptoms

CPT only lists seven HPI elements, with duration not making the list. Therefore, for Medicare payers, you should consider duration and timing separately. With payers that follow CPT, however, be aware of this distinction.

Start Counting to Differentiate Brief, Extended

There are two different types of HPI: brief and extended. If your general surgeon documents one to three HPI elements, then he performed 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 including 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Alternative: When your surgeon documents four or more HPI elements, you have 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).

Example: A brief HPI might be appropriate for a follow up for an 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," Stoltman says.

Caution: An extended HPI does not guarantee a higher-level E/M code, but it does make reporting it possible. Ensure your surgeon has met the other required elements of service before choosing hese high-level codes.

"Make sure your doctors obtain and document as much information as possible to allow billing a higher level E/M," says Ruth Borrero, claims analyst at Prohealth Care in Lake Success, N.Y.

Ensure that the Provider Documents the HPI

Remember that the physician alone must be the one who obtains the HPI. He cannot only use or report the information obtained by his staff. Your surgeon 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, Borrero says. 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.

Important: "The physician, or other licensed provider, needs to reference the information provided," Stoltman warns. "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."