Oral Surgery Coding & Reimbursement Alert

Ensure that payer recognizes ‘duration’ before counting it on HPI.

Whenever your clinician performs an evaluation and management (E/M) service, the history of present illness (HPI) is one among the many factors that play a crucial role in influencing the E/M level that you will report.

Anyone who has to select a code for an office E/M service needs to know about HPI.

Why? You can’t choose the correct E/M level for an initial encounter without knowing the HPI level. If you deem the HPI too high, you’ll be overcoding and exposing your practice to auditors. On the other hand, you’ll undercode if you get HPI too low, which could cost the practice cash.

Check out this crash course on HPI basics, along with a couple of case studies to illustrate the issue.

First, Know HPI Definition

HPI is a “chronological description of the development and/or progress of the patient’s present illness/injury,” explains Yvonne Bouvier, CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind. Providers take HPI when interviewing the patient about the condition that caused them to visit the practice.

The provider should get the description from the patient’s own words during the encounter; “from the first sign and/or symptom, or from the previous encounter, to the present visit,” explains Bouvier.

Check Which Element List You Should Use

Depending on the payer, there are seven or eight HPI elements, reminds Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash. For Medicare and Medicaid payers, the HPI elements are:

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

Caveat: CPT^® does not include duration in its list of HPI elements, so some private payers that follow CPT^® rather than Medicare guidelines might only use the seven elements. If you are unsure of a payer’s HPI element list, look for a published copy of their audit tool or call your representative to check.

Use 3-Element Limit for Brief HPI

Once you’ve got a handle on what HPI is and which element list you’ll use, you’re ready to check the encounter notes to see whether the provider performed a brief or extended HPI.

When a provider reviews one to three elements during the E/M, she is performing a brief HPI, confirms Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb. “These numbers and the ones defining an extended HPI come from the documentation guidelines for E/M services maintained by the Centers for Medicare & Medicaid Services (CMS),” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Because CPT^® considers a brief HPI part of a problem-focused or expanded problem-focused history, it can support the following initial E/M office visit levels:

• 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…) and 99202 (…an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making…) for new patients.
• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional…), 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…) and 99213 (… an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) for established patients.

Scenario: A 45-year-old male patient reports to your clinician with a chief compliant of pain in the right side of the jaw (location). The patient reports that the pain has been present for more than three weeks (duration) now.

HPI: Your clinician reviewed two elements, so this is an example of a brief HPI.

Count to 4 Elements Before Considering Extended HPI

When your provider reviews four or more elements during the E/M, she is performing an extended HPI, Swanson says.

Having enough elements to qualify as an extended HPI supports a detailed or comprehensive history. When you spot an extended HPI on an encounter form, it might make the visit eligible for the following initial E/M office visit levels:

• 99203 (… a detailed history; a detailed examination; medical decision making of low complexity…), 99204 (… a comprehensive history; a comprehensive examination; medical decision making of moderate complexity…) and 99205 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity…) for new patients
• 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity…) and 99215 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity…) for established patients.

Caveat: An extended HPI does not guarantee a higher-level E/M code; it only makes reporting these E/M codes possible. The provider must still satisfy other encounter requirements (review of systems [ROS] level; past, family, social history [PFSH] level; physical exam level; medical decision-making level) in order to select a higher-level E/M office visit code.

Scenario: In the previous example, your clinician asks the patient:

• where the pain is centered (location)
• how long he has had the pain (duration);
• how he would describe the pain (quality);
• how bad the pain is on a scale of 1-10 (severity);
• if the pain is worse in the daytime or when he is trying to sleep (timing)
• if he has any headache, fever, nausea or other symptoms (associated signs and symptoms); and
• if he has taken any medications to deal with the pain (modifying factors).

HPI:  Since in this scenario, your clinician reviewed seven factors, this case is an example of extended HPI.

Another Standard for an Extended HPI

“Be aware that the 1997 version of CMS’s E/M documentation guidelines includes an alternative definition of an extended HPI,” Moore says. “According to those guidelines, you may also claim an extended HPI if the medical record describes ‘the status of at least three chronic or inactive conditions.’ So, for example, if your clinician noted that the patient also suffered from diabetes, hypertension, and congestive heart failure and comments on the stability of each of those conditions at the time of the encounter, you could claim credit for an extended HPI under the 1997 E/M documentation guidelines, regardless of the number of elements noted regarding the anxiety attacks. Such an extended HPI is more common in a primary care or for established patients, but it is not limited to any particular specialty or visit type,” Moore adds.

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