Ob-Gyn Coding Alert

Take this step toward fixing your E/M documentation.

If you’re planning to tighten up your practice’s E/M coding (as advised in our cover story), the history of present illness (HPI) is a good place to start. Multi-symptom patients can be the top order of your day, so learn to analyze the charts and count correctly to reach the correct HPI level.

Here’s why: You count HPI (history of present illness) elements for each case because they’re an important part of the history component of E/M services. A “brief” HPI consists of one to three elements, and an “extended” HPI requires four or more elements as described below. 

Having enough elements to qualify as an extended HPI means the care might qualify for a detailed or comprehensive history. Documenting an extended HPI makes reporting a higher E/M code possible, but does not guarantee that step. The physician still must satisfy the review of systems (ROS) and past, family social history (PFSH), as well as the other major elements of service (physical exam and medical decision-making).

Tally These Elements of Patient’s Condition

For coding purposes, HPI is an ordered description of the patient’s current condition. Many practices use a template to keep track of which elements go toward the HPI, which are location, quality, severity, duration, timing, context, modifying factors and the associated signs and symptoms reported by the patient. When you count elements, check to see how many of these eight questions are documented in the notes.

1. What is the physical location of the problem on or in the body? (Location)

2. How is the symptom further described, related to the type of pain? (Quality)

3. How intense is the problem or related pain? (Severity)

4. How long has the patient had the problem? (Duration)

5. Is the problem better or worse at any time of the day? (Timing)

6. How did the injury occur? (Context)

7. What can the patient do (or what has the patient done) to alleviate or aggravate the pain? (Modifying factors)

8. What other symptoms and signs does the patient have in relation to the chief complaint? (Associated signs and symptoms)

Check How Elements Come Together

Now that you’ve refreshed your memory on how to count HPI elements, put your knowledge to the test with these common ob-gyn scenarios.

Patient 1: Mary presents to her ob-gyn with vaginal discharge and itching. She states it started four days ago and that she tried a douche to see if that would help, but it did not. She denies any fever or urination pain or urinary frequency. 

Chief complaint: Vaginal itching 

HPI count: Location (vagina); duration (four days); modifying factors (douche). 

Review of systems (ROS): Genitourinary and constitutional.

You’ve documented a brief HPI with three elements (location, duration, and modifying factors).

PFSH: Not addressed

Patient 2: Linda presents with a growth on her outer labia that has been bothering her for eight months. She would like it removed because it feels odd. She denies any bleeding from the growth and says it is not getting any bigger than when she first noticed it. 

Chief complaint: growth on vulva

HPI count: Duration: 8 months; quality (feels odd), location (outer labia) 

ROS: Integumentary

PFSH: had a sebaceous cyst of the vulva removed in 2010 

In this case you have another brief HPI with two or three documented elements (duration, quality, and location).

E/M choice: The documentation for both patients is consistent with the HPI elements required to report a mid-level E/M code. Choose 99202 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) as appropriate. You must document four HPI elements before qualifying for 99214. This would also require two or more elements of the ROS and one element of PFSH, as well as appropriate exam and/or MDM.

Remember to Keep Totals Current

Keep in mind that your documentation must stand for itself each day. If the patient is in the hospital for several days or visits your office several days in a row, you can’t count the HPI listed in yesterday’s documentation for today. If you want it counted for today, you must repeat the information each day.  

Also, be sure if you are using an EMR that counts the elements that the elements are in fact identified correctly. In other words, counting should not be based on the number of items documented, but rather on the number of element categories documented since each HPI element can have more than one statement that would qualify for reporting it.