Optometry Coding & Billing Alert

CPT, CMS don't see eye-to-eye on duration.

Not accurately counting history of present illness (HPI) elements can land you on lower-level E/M codes, which could cost your practice deserved payment.

Solution: Use this guide to nail down chart notes' HPI elements.

For coding purposes, "HPI is the chronological description of development of the present illness from first sign or symptom, or prior encounter, to present," explains Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. Depending on the payer, there are seven or eight HPI elements. For Medicare and Medicaid payers, the HPI elements are:

• Location

• Quality

• Severity

• Duration

• Timing

• Context

• Modifying factors

• Associated signs and symptoms.

Heads up: CPT does not include duration in its list of HPI elements, so the AMA has seven elements. If you are unsure of a payer's HPI element list, call your representative to check.

HPI is one of the three parts comprising an outpatient E/M service's history component. There are two levels of HPI: brief and extended. A brief HPI consists of one to three elements, confirms Heather Smith, CPC, CMC, clinic coding/auditing coordinator for Michigan's South Haven Community Hospital.

For a new-patient encounter, a brief HPI can support up to 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...). For established patients, a brief HPI can support up to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...), Smith says.

When the optometrist satisfies four or more elements, she has performed an extended HPI, says Falbo. The physician must achieve an extended HPI to document at least a detailed history -- meaning that extended HPI is a requirement for all new patient E/Ms above 99202; and all established outpatient E/Ms beyond 99213 if they rely on history as one of the key components.

Extended HPI does not guarantee a higher-level E/M code, but it does make reporting it possible. The optometrist still has to satisfy other elements of service before choosing these high-level codes.

Example: A patient says he has difficulty driving. To justify an extended HPI, the optometrist needs to probe a little farther. Does the patient have difficulty driving at night? Difficulty reading road signs? Does the glare of  headlights at night create problems? A really clarifying statement to put in the medical record is that the patient has difficulty driving at night due to glare of the headlights, and has had this difficulty for the past year.

This includes location (eye), quality (difficulty driving), timing (at night), duration (past year), and context (glare). This amounts to five elements, which exceeds the minimum required for an extended HPI.

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

• What is the location of the problem? (location)

• What is the quality of the problem? (quality)

• 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.

Caution: If the optometrist just checks off the questions he asked the patient, ask him for encounter details to ensure proper HPI level. With HPI recording, the optometrist should document "the unique situation of each patient at each encounter to clearly substantiate the medical necessity of the service(s) rendered that day," explains Falbo.