Medicare Compliance & Reimbursement

Differentiate brief history of present illness from extended with these tips.

Question: Our coding staff has a disagreement about how to differentiate a brief history of present illness (HPI) from an extended HPI. Our office manager feels that our practice has had to downcode some claims from a higher E/M level to a lower one simply because the physician either isn't documenting the HPI completely, or because our coding staff downgrades the HPI. We'd love some advice on what the difference is.

Answer: You can distinguish between brief and extended HPIs based on the detail the physician needs to accurately characterize the clinical problem(s).

Specifically, a brief HPI consists of one to three elements, but an extended HPI consists of four or more elements, according to the CMS "1995 Documentation Guidelines for Evaluation & Management Services" (www.cms.gov/MLNProducts/Downloads/1995dg.pdf).

Important: Remember when choosing an E/M code that history is only one component, and you must consider the level of exam, medical decision making, and the nature of the presenting problem as well before settling on the correct E/M code.

An extended HPI is necessary to reach a detailed or comprehensive history, and, thus, qualify for the higher levels of E/M services. For instance, established patient office visit code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...) requires a detailed history, which requires that the physician perform and document an extended HPI (four or more elements), extended review of systems (ROS) (two or more systems), and a pertinent past, family and/or social history (PFSH) (one of the three).

Documenting only three HPI elements will restrict you to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity). On the hospital side, a brief HPI of three elements will limit you to the lowest-level admission code, 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...).

If you discover that the physician is performing an extended HPI but is not documenting it, you should schedule an educational session with that doctor to advise him on how to appropriately document. Let him know how much money he is leaving on the table if he's consistently causing claims to be downgraded due to his missing documentation.