General Surgery Coding Alert

Break Down HPI for Maximum Efficiency Question: An internal chart audit of our E/M claims showed that our history of present illness (HPI) levels lessened the rightful service level of some claims. How can we get the most accurate HPI level for each E/M?

Montana Subscriber Answer: Getting a full picture of a patient's medical history is a difficult challenge, but one you can meet. These elements go toward determining HPI:

Location is the place on the patient's body where the injury occurred (-on the left forearm,- for instance).

Context is what the patient was doing when the injury or trauma occurred (such as -patient had chest pain while climbing stairs-).

Quality represents the chief complaint or signs or symptoms. So if a patient reports with a dull pain in her lower extremities, -dull- is the quality.

Timing is the time of day the patient experienced the signs and symptoms. If the notes say, -Severe depression at night, last two weeks,- -at night- is the timing.
 
Severity shows just how serious the patient's condition is. Physicians often show severity in their notes with a scale of 1 (least painful) to 10 (most painful).

Duration is how long the patient's signs and symptoms have been present (for instance, -Patient has had severe headache, last four hours-).

Modifying factors are things the patient did himself to alleviate the pain, as well as the things the patient did to make the symptoms worse (for example, -Patient's chest pain was worsened by his pacing around the room- or -Pain improved when patient sat and breathed deeply-).

Associated signs and symptoms are any other problems the patient has in addition to the chief complaint (e.g., blurred vision might be an associated symptom of a severe headache).

For most upper-level codes, the physician should cover and document in the HPI documentation a minimum of four of these points.