Internal Medicine Coding Alert

Here’s the fast, easy way to get beyond CC.

During the history of present illness (HPI) portion of an E/M service, the first order of business is getting the patient to establish a chief complaint (CC). From there, you ask about each of the HPI components individually to get a fuller picture of the patient’s condition.

Problem: It might be pretty easy to get a CC out of a patient, but how do you continue with the HPI questions after you establish the CC?

Solution: For answers, we turned to Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.

It’s all in the details …

After you establish the CC, Swanson recommends continuing  the  E/M  evaluation  with  these  follow-up  questions that address each of the HPI components:

1. Location: “Is the symptom located in a specific place? Has this changed over time? If the symptom is not focal, does it radiate to a specific area of the body?” says Swanson.
2. Quality: “When describing pain, ask the patient to further describe the pain, if it’s like anything else that they’ve felt in the past. Knife-like? A sensation of pressure? Aching pain?” Swanson explains. “If it affects their activity level, determine to what degree this occurs. For example, if they complain of shortness of breath [SOB] with walking, how many blocks can they walk? How does this compare with six months ago?”
3. Severity: “How bothersome is this problem? Does it interfere with your daily activities? Does it keep you  up  at  night?”  Swanson  offers.  “If  the  patient  is  describing pain, ask them to rate it from 1 to 10 with 10 being the worst pain.”
4. Duration: “How long has this condition lasted? Is it similar to a past problem? If so, what was done at that time?” says Swanson. (Note: Some third-party payers might not consider duration an HPI component.)
5. Timing: How often does the problem occur? Daily, weekly,  monthly,  etc.
6. Modifying factors: What has made the CC better (or worse)? Rest, eating, etc.? What have the patient and the physician done so far that has made the problem better or worse?
7. Context: Does this problem occur at a certain time, or in certain situations? Is it better or worse when you do certain things, such as after eating, before bed, etc.? Where was the patient/what was the patient doing when the symptoms began?
8. Associated signs and symptoms:  Have  you  experienced  any  other  problems  at  the  same  time  as  the  CC?  (Nausea/vomiting,  pain,  headache,  etc.)  “The  patient  may  notice  other  things  that  have  come  up  around  the  same  time  as  the  dominant  problem,”  explains  Swanson.  Ask  the  patient  to  explain  any  associated  symptoms  further,  as  the  issues  may  be  related.  

Go above and beyond

In addition to the above queries, Swanson recommends that you ask the patient what he thinks the problem is and what he is concerned about.

“This  may  be  particularly  relevant  when  a  patient  chooses  to  make  mention  of  symptoms  or  complaints  that  appear  to  be  longstanding,”  Swanson  says.  In  these  instances,  it  could  be  beneficial  to  ask  additional  HPI  questions  such  as:

• Is there something new/different today as opposed to every other day when this problem has been present? Does this relate to a gradual worsening of the symptom itself?
• Have you developed a new perception of the problem’s  relative  importance  (for  example,  a  friend  told the patient to get it checked out)?

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