Ophthalmology and Optometry Coding Alert

If you stumble over the elements that comprise an E/M service's history of present illness (HPI), you may incorrectly go with an eye code.

Leave no HPI element uncovered with these tips.

Spot These 8 HPI Elements

Your ophthalmologist must take/record the HPI, which is a chronological description of the development of the patient's present illness from the first sign or symptom from the previous encounter to the present.

HPI elements include:

• Location: where the illness is on the body -- such as left eye, right eyebrow, cornea.

• Quality: a description of the illness -- for instance, aching, stabbing, itchy.

• Severity: a measure of how bad the illness is -- such as on a scale of 1-10.

• Duration: how long the illness has been present -- for instance, last two weeks.

• Timing: when do the signs/symptoms appear -- on and off, at night.

• Context: what the patient was doing when the illness first appeared -- such as while swimming or while playing ball. Context may also describe the background circumstances that occurred prior to the patient presenting to your office for work-up -- such as "seen by Dr. Jones and treated with two courses of antibiotics, which has not resolved the problem and now presents to us for evaluation."

• Modifying factors: what circumstances or what the patient has done to make the signs/symptoms worse or better -- for instance, worst on waking or not as itchy after eye drops.

• Associated signs or symptoms: any signs or symptoms directly related to the illness.

You need one to three elements for a brief HPI. Most auditors stop counting HPI when they reach four elements, which is an extended HPI. The status of three chronic or inactive conditions also counts for extended HPI using the 1997 documentation guidelines.