Oncology & Hematology Coding Alert

Get your oncologist to collect the information you need with this handy list.

Mastering history of present illness (HPI) for your oncologist's E/M services was the focus of "HPI Know-How Helps You Catch Level 4 and 5 E/M Opportunities" (see Oncology & Hematology Coding Alert, vol. 13, no. 6). Now, take that knowledge a step further with the checklist below. It will help you determine the HPI level a service meets.

When counting elements of HPI, check to see how many of these eight questions your oncologist answers in the notes:

• What is the location of the problem? (location of pain, mass, or organ involved)
• What is the quality of the problem? (nature of the pain, such as dull, sharp, or colicky)
• How intense is the pain or problem? (severity)
• How long has the patient had the problem? (duration)*
• Is the problem better or worse at any time of the day? (timing)
• What is the setting or circumstances in which the problem occurs? (context)
• What can the patient do to alleviate or aggravate the problem? (modifying factors)
• What other symptoms and signs does the patient have in relation to the chief complaint? (associated signs and symptoms)

*Note: Payers that follow CPT® guidelines won't accept duration as an HPI element, so don't include it in your HPI count for those claims.