Neurosurgery Coding Alert

Question: We have a provider who believes that if she has an extended HPI, then she can report the high-level E/M codes, but I don’t agree with her reasoning. Can you help us out?

Hawaii Subscriber

Answer: You are correct. An extended history of present illness (HPI) does not guarantee a higher-level evaluation and management (E/M) code, but without an extended HPI you aren’t able to report a high-level E/M. The physician must document an extended HPI to document a detailed or comprehensive history. An extended HPI is a requirement for 99203-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) and 99214-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Describing the history of present illness starts from the first symptom to the current condition and may include the location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. A brief HPI requires one to three elements. An extended HPI requires four elements or the status of three chronic or inactive conditions.

Determining an overall level of service depends on three key components: history, medical examination, and medical decision making (MDM) for new patients and two of three components for established patients. The history portion of an E/M service requires all three elements — HPI, review of systems (ROS), and past medical, family and social history (PMFSH). Unlike the ROS and PFSH elements of a history, the HPI must be documented by the reporting provider.

Since you determine the level of history for an encounter based upon more than just HPI, and you determine the overall service level based upon more than just history, extended HPI alone won’t guarantee the higher-level code.