Part B Insider (Multispecialty) Coding Alert

Understanding each patient's history of present illness (HPI) is key to top-notch E/M coding. If audits show that you-re missing the mark when coding E/M service levels, brush up on these eight areas that contribute to determining HPI:

1. Location is the place on the patient's body where the symptoms exist (-the lower back,- for instance).

2. Context is what the patient was doing when the problem occurred (such as -patient had lower back pain after standing on his feet all day-).

3. Quality represents the chief complaint or signs or symptoms. So if a patient reports with a sharp pain in her shoulder, -sharp- is the quality.

4. Timing is the time of day the patient experienced the signs and symptoms. If the notes say, -Pain after standing for long periods, last two weeks----after standing for long periods- is the timing.

5. Severity shows just how serious the patient's condition is. Physicians often show severity in their notes with a scale of 1 (least painful) to 10 (most painful).

6. Duration is how long the patient's signs and symptoms have been present (for instance, -Patient has had sharp/severe shoulder pain, last three weeks-).

7. Modifying factors are what the patient did herself to alleviate pain--or exacerbate the symptoms (for example, -Patient's low back pain was worsened by continuing to stand for long periods- or -Pain improved when patient sat for 15-20 minutes-).

8. Associated signs and symptoms are any other problems the patient has in addition to the chief complaint (such as blurred vision, an associated symptom of migraines).

For most upper-level E/M codes, the physician must cover and document in the HPI documentation a minimum of four of these points.

Tip: -Once you get to four, you can stop counting because the highest level is an extended HPI, which is four or more elements,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CodeRyte Inc. coding analyst and coding review teacher.

Your physician should only cover HPI elements that are relevant to the chief complaint and to level of medical decision-making. In other words, your physician should not list irrelevant HPI elements just to increase the level of HPI. If the patient's condition only meets straightforward medical decision-making, it may not be relevant to list an answer to each element of the HPI.