Neurology & Pain Management Coding Alert

Question: Could you explain the basics of history of present illness (HPI) coding? What difference does it make to our evaluation and management (E/M) coding?

Iowa Subscriber

Answer: When you are poring over encounter notes looking for the portions of an E/M service your physician provided, be sure to focus on the patient’s history of present illness (HPI).

Reason: There are two types of HPI: brief and extended. You cannot code for higher-level E/Ms without an extended HPI. Get to know how to spot each HPI element with this quick primer.

For coding purposes, CPT^® identifies seven possible HPI “elements”:

• Location
• Quality
• Severity
• Timing
• Context
• Modifying factors
• Associated signs and symptoms

Also: Medicare, and most private payers, consider “duration” an eighth HPI element. If you are unsure of your insurer’s policy on duration, check with it before filing the claim.

If your physician reviews and documents one to three of the HPI elements, then the HPI is brief. A brief HPI will support up to 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making…) for new patients, and 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…) for established patients

If your physician reviews and documents four or more elements, she has performed extended HPI. Depending on the other specifics of the encounter, an extended HPI could warrant a 99203 code or higher for new patients, and 99214-99215 for established patients. (Extended HPI is not a guarantee of a high-level E/M code, but you cannot report a high-level E/M code without an extended HPI.)

Example: An established patient reports to the office with a complaint of shoulder pain from a tennis injury (Context). The patient has a history of diabetes (Modifying factor). During the E/M, the physician specifies that the pain is centered in the upper right clavicle area (Location).  Encounter notes indicate that the patient reports a 7/10 on the pain scale (Severity). When the pain is at its worst, the patient reports a dull, aching neck pain accompanies the shoulder discomfort (Associated signs and symptoms).

In this example, the physician provided extended HPI, as she reviewed five elements.