Ophthalmology and Optometry Coding Alert

Beware of CPT® and Medicare differences when counting HPI elements.

Not accurately accounting for the history of present illness (HPI) documented by your ophthalmologist could result in missing appropriate opportunities to report level 4 or 5 E/M visits. Ensure you're not missing higher paying possibilities by reviewing this guide to capturing HPI elements.

Brush Up on What Qualifies as an HPI Element

HPI is one of the three elements comprising an E/M history. It describes the patient's present illness or problem, from the first sign/symptom to the current status, and typically drives a provider's decisions about the physical examination, diagnostic tests, and treatment.

"The information gathered during the physical exam (PE) portion of a patient's evaluation often only shows a very limited picture of the patient's problem. However, speaking with a patient and gathering the history of the patient's problem" can help fill out the picture, explains Amanda S. Stoltman, CCS-P, compliance coder at a practice in Muncie, Ind.

Start counting: HPI also will contribute to determining the level of service you'll report. There are seven or eight HPI elements, depending on which source you are following. For Medicare, the eight elements are as follows:

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

Medicare includes the above list in both the 1995 and 1997 E/M Documentation Guidelines, available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

In contrast: CPT® lists only seven HPI elements in the E/M Services Guidelines, with duration not making the list.

Therefore, for Medicare and payers following its guidelines, you should consider duration and timing separately. With payers that follow AMA rules, however, be aware that they don't consider duration and timing to be two separate elements. Rumor has it this may change in a future edition of CPT®, though. Keep an eye out for 2012 revisions.

Start Counting to Differentiate Brief, Extended

There are two different types of HPI: brief and extended. If your ophthalmologist documents one to three HPI elements, then he performed a brief HPI. When you have a brief HPI you won't be able to code any higher than a level two new-patient E/M (99202, Office or other outpatient visit for the evaluation and management of a new patient ...), regardless of the encounter's other specifics. For an established patient, a brief HPI can support up to and including 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) (assuming other requirements are met).

The reason is that with only a brief HPI, the highest possible history level is "expanded problem focused," according to the 1995 and 1997 documentation guidelines (assuming the visit meets the other history elements).

Alternative: When your ophthalmologist documents four or more HPI elements, you have extended HPI. Your physician must achieve an extended HPI for you to consider a detailed or comprehensive history. An extended HPI is a requirement for 99203-99205 (new patients) and 99214-99215 (established patients).

Example: "An extended HPI would include (especially if the patient is doing poorly) the length of time the current problem has been going on, what seems to make the problem better or worse, if it is worse during a particular portion of the day, the severity, and if the patient has any other signs/symptoms," Stoltman says. And of course, for an ophthalmology practice, the location is "eyes".

Caution: An extended HPI does not guarantee a higher level E/M code, but it does make reporting it possible. Ensure your ophthalmologist has met the other required elements of service before choosing these high-level codes. "Make sure your doctors obtain and document as much information as possible to allow billing a higher level E/M," says Ruth Borrero, claims analyst at Prohealth Care in Lake Success, N.Y. However, remember that medical necessity for collecting that information is a key element of supporting the code you choose.

Ensure the Provider Documents the HPI

Remember that the physician must be the one who obtains the HPI. He cannot use or report the information obtained by his staff. Your ophthalmologist must personally obtain, rewrite or restate, and document the HPI if he expects to receive credit and reimbursement for services where the HPI becomes critical to scoring the E/M level of care. Just adding to the HPI obtained by staff does not meet this requirement. Only the physician should obtain and document the HPI.

Any employee in your practice, or even the patient himself, can document the other two elements of the history, Borrero says. In fact, the E/M service documentation guidelines state that ancillary staff may obtain and record the review of systems (ROS) and/or past family social history (PFSH).

However, documentation guidelines require that the information obtained by others must be attested to. Specifically E/M guidelines state, "To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others." This pertains to the ROS/PFSH as allowed by the guidelines.

Reminder: "The physician, or other licensed provider, needs to reference the information provided," Stoltman warns. "Since the HPI should be the driving force behind the type of evaluation provided to a patient and treatment options, the HPI most definitely should only be documented by the physician."