Otolaryngology Coding Alert

Question: I'm auditing a note that states: "CC: A patient seen in the office complains of left ear pain. HPI: Patient complains of dull ache in left ear over the past 24 hours."

Does the note support a brief or extended history of illness (HPI)?

Maryland Subscriber

Answer: The note includes three HPI elements, which the AMA and CMS consider brief HPI You have location / chief complaint (left earache), quality (dull), , and duration (over past 24 hours). The other HPI elements include severity, associated signs and symptoms, timing, context and modifying factors. See if you can spot the additional HPI elements in this note:

"Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and ibuprofen." In addition to the same location, quality and duration elements listed in your note, the second note also indicates:

• context (went swimming)
• modifying factors (relieved by warm compress and ibuprofen).