Part B Insider (Multispecialty) Coding Alert

Strong documentation is needed to fully address patients’ HPI to avoid claims’ denials.

It’s important that you choose the correct History of Present Illness (HPI) level based on the documentation written by the physician for each of your E/M claims if you want to get the most out of your providers’ services.

Why? The documentation must support a certain level of HPI in order to code for most appropriate the E/M level of service.

Take a look at these answers on what HPI is, why it’s important, and how you can use HPI knowledge to solidify your bottom line.

Consider HPI Part of History

History, examination, and Medical Decision-Making (MDM) are the three key components in selecting the level of E/M service, in most cases. HPI is one element within the history component, explains Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.

“Obtaining the patient’s HPI is an important first step in determining the etiology of a patient’s problem. The HPI information can assist a practitioner in arriving at the patient’s diagnosis,” says Swanson.

According to CPT® 2016, HPI is “a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem.”

To start the HPI conversation, the provider usually asks the patient to describe his problem, Swanson says. The practitioner may ask the patient any one or more of the following questions to get into the HPI discussion:

• What brings you to the clinic today?
• How can we help you?
• What seems to be the problem?

Code Higher-Level E/Ms With Extended HPI

There are two levels of HPI; brief and extended. You tally HPI by reviewing the notes and deciding how many of the following elements the provider reviewed relative to the patient’s CC:

• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associated signs and symptoms.

Potential pitfall: Medicare payers consider all of the above HPI components. Some payers, however, 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.

According to Yvonne Bouvier CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind., when the provider performs a brief HPI, she documents one to three HPI components. A brief HPI will support the following office visit E/M codes (assuming the rest of your documentation supports these codes), Bouvier confirms:

• 99201 (Office or other outpatient visit for 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) or 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. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) through 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) for established patients.

Use Extended HPI to Potentially Unlock Higher E/Ms

If the provider conducts and documents an extended HPI you might be able to report:

• 99203 (… a detailed history; a detailed examination; medical decision making of low complexity) through 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.

Caveat: The extended HPI does not guarantee that you can report one of the above-listed E/M codes. The visit must meet other necessary elements as well. However, without an extended HPI, you may not be able to report any of the above higher-level E/M codes.  

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