Otolaryngology Coding Alert

Question: How does a brief history of present illness (HPI) differ from an extended HPI?

Michigan Subscriber

Answer: You can distinguish between brief and extended HPIs based on the detail the otolaryngologist needs to accurately characterize the clinical problem(s). Specifically, a brief HPI consists of one to three elements, but an extended HPI consists of four or more elements, according to the CMS "1995 Documentation Guidelines for Evaluation & Management Services" (www.cms.gov/MLNProducts/Downloads/1995dg.pdf).

Important: Remember when choosing an E/M code that history is only one component, and you must consider the level of exam, medical decision making, and the nature of the presenting problem as well before settling on the correct E/M code.

An extended HPI is necessary to reach a detailed or comprehensive history, and, thus, qualify for the higher levels of E/M services. For instance, established patient office visit code 99214 (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 detailed history; a detailed examination; medical decision making of moderate complexity ...) requires a detailed history, which requires that the physician perform and document an extended HPI (four or more elements), extended review of systems (ROS) (two or more systems), and a pertinent past, family and/or social history (PFSH) (one of the three).

Documenting only three HPI elements will restrict you 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). On the hospital side, a brief HPI of three elements will limit you to the lowest-level admission code, 99221 (Initial hospital care, per day, for the evaluation and management of a patient ...).