Orthopedic Coding Alert

Question: What elements should we look for when selecting the history of present illness (HPI) level?

North Dakota Subscriber

Answer: The history of present illness (HPI) is an element within the history component - one of the three key factors used in selecting the correct level of E/M service. The CPT^® 2017 manual defines HPI as "a chronological description of the development of the patient's present illness from the first sign and/or symptom to the present."

Obtaining the patient's HPI is an important first step in determining the etiology of a patient's problem, according to Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska. The HPI information can assist a practitioner in arriving at the patient's diagnosis.

The physician will ask the patient to describe his problem, to start the HPI conversation, Swanson says. The physician may ask the patient any one or more of the following questions to get into the HPI discussion:

• What brings you to the clinic today?
• How can we help you?
• What seems to be the problem?

There are two levels of HPI - brief and extended. You tally HPI by reviewing the notes and deciding how many of the following elements the provider reviewed relative to the patient's chief complaint (CC):

• Location: The anatomical place or site of the chief complaint
• Quality: Further description of the problem (stabbing, achy, itchy, etc.)
• Severity: The degree of intensity of the signs or symptoms
• Duration: Length of time of the complaint
• Timing: How often the symptoms occur
• Context: The circumstances/environment in which the symptoms occur
• Modifying factors: Anything that relieves or aggravates the problem
• Associated signs and symptoms: Other related factors or symptoms.

Brief HPI: With a brief HPI, the documentation would illustrate one to three of the above elements.

Extended HPI: With an extended HPI, the documentation would include four or more of the above elements.

Remember: Some payers don't consider duration as a separate element, as CPT^®  does not include it in its list of HPI components. If you are unsure of a payer's HPI element list, call your representative to check and then document the response.