Internal Medicine Coding Alert

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 it's one you can meet. These elements go toward determining HPI:

Location is the place on the patient's body where the symptoms exist ("on the left forearm," for instance).

Context is what the patient was doing when the problem 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 evaluation and management codes, the physician must cover and document in the HPI documentation a minimum of four of these points.  

However, they should only cover HPI elements that are relevant to the chief complaint and to the level of medical decision-making. In other words, they should not list HPI elements that are not relevant just to increase their level of HPI. If the patient's condition only meets straightforward medical decision-making, it may not be relevant to list an answer to each element of the HPI.