Otolaryngology Coding Alert

Question: The patient complains of a sore throat for the past three weeks. It is usually worse at night. What factors need to be documented in order to reach an extended HPI?

Answer: There is a total of eight different elements that you may account for when determining the level of HPI:

• Location:  The anatomical place or site of the chief complaint, in this case, "sore throat"
• Quality: Further description of the problem (stabbing, achy, itchy, etc.)
• Duration: Length of time of the complaint, in this case "for the past 3 weeks"
• Severity: The degree of intensity of the signs or symptoms
• Timing: How often / when the symptoms occur, in this case, "worse at night"
• 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.

You will determine the patient's level of HPI by determining which of these elements the documentation accounts for.  If you are only able to document one to three of these elements, you will reach a level of brief HPI. To reach an extended HPI level, four or more of the above elements will need to be documented by you or the provider.

In this case, you only have 3 HPI elements documented. Had the provider documented one more, such as "Ibuprofen helps reduce the pain" (Modifying factors), or "the pain is a 7 on a scale of 10" (Severity), etc, the fourth HPI element would have qualified the note as an extended HPI.

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.