Otolaryngology Coding Alert

Question: An established patient reports to the otolaryngologist with a chief complaint of throat pain. Notes indicate that the otolaryngologist asked the patient the location of the pain, how severe the pain is, how long the pain has lasted, and whether the pain is accompanied by any other issues. Which level of history of present illness (HPI) is this encounter?

Arkansas Subscriber

Answer: It depends on the insurer’s policy, as your encounter lies right on the line between two HPI levels.

The rules: CPT^® lists seven elements on its HPI list: location, quality, severity, timing, context, modifying factors, associated signs and symptoms), but Medicare includes duration as an eighth element. Depending on which rules the payer follows, your otolaryngologist reviewed three or four systems. Three for a Medicare payer, and four for a payer that’s governed by CPT^® guidelines.

Your claim: If you’re reporting the claim to a Medicare-observant payer, your otolaryngologist performed an extended HPI. Conversely, if you’re reporting the claim for a patient insured by private payers, your otolaryngologist performed a brief HPI.

Most payers accept duration as an HPI element. If you have a payer who is disallowing duration, you might be able to win on appeal once you show how relevant the duration is to understanding the problem’s history. Without duration, the HPI is an incomplete picture, so be sure to appeal if a payer denies duration as an HPI element.

Why it matters: CPT^® rules dictate that brief HPI can only be part of problem-focused or expanded problem-focused history; therefore, brief HPI can support the following office visit E/Ms:

• 99201 (Office or other outpatient visitfor 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.

If you’ve got an extended HPI, it might mean that you can code for a detailed or comprehensive history; therefore, extended HPI can support the following office visit E/Ms:

• 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.

Remember: An extended HPI does not guarantee a higher-level E/M code; it only makes reporting these E/M codes possible. Always keep your E/M coding within the scope of medical necessity of the patient’s presenting problem. If the otolaryngologist performs a comprehensive history and detailed exam on a relatively simple problem — such as an earache — you will be hard-pressed to justify more than a level-two or -three E/M for the encounter. The patient would have to have significant co-morbidities, and possible failed treatments and recurrences, to justify a higher-level E/M.

Warning: Payers are always on the lookout for artificially inflated HPI levels on claims, as they can affect the level of evaluation and management (E/M) service you code. The physician should only cover HPI elements that are relevant to the chief complaint. Listing irrelevant HPI elements to increase levels could raise red flags with payers.