Part B Insider (Multispecialty) Coding Alert

Differentiate location from context and you-ll be in the clear

Question: An internal chart audit of our E/M claims shows that our history of present illness (HPI) levels lessened the rightful service level of some claims. How can we get the most accurate HPI level?

Answer: Getting a full picture of a patient's medical history is a difficult challenge, but it's one you can meet. The following elements go toward determining HPI:

- Location is the place on the patient's body where the symptoms exist (-the lower right quadrant,- for instance) or the particular organ from whence the symptoms arise (for example, prostate, kidney, etc.).

- Context is what the patient was doing when the problem occurred (such as -pain after urinating-).

- Quality represents the characteristics of the chief complaint or signs or symptoms. So if a patient reports dull pain in her lower abdomen, -dull- is the quality.

- Timing is the time of day the patient experienced the signs and symptoms. If the notes say, -Pain after waking in the morning, last two weeks,- -after waking in the morning- is the timing.

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

- Duration is how long the patient's signs and symptoms have been present (for instance, -severe knee pain, last two weeks-).

- Modifying factors are things the patient did to try to alleviate the pain, as well as the things the patient did that made the symptoms worse (for example, -Patient's pain was worsened by exercise-).

- Associated signs and symptoms are any other complaints the patient has in addition to the chief complaint (lower back pain, fever).

For most upper-level E/M codes, the physician must cover and document a minimum of four of these points in the HPI. Occasionally a patient may have more than one chief complaint (pain in the left testicle and simultaneous pain in the right kidney), and under these clinical circumstances you still need only the four elements (not eight) for an upper-level E/M service.

In the above example, you can count -location- of pain twice, once for the left testicle and once for the right kidney. Keep in mind that your doctor should only cover HPI elements that are relevant to the chief complaint and to the level of medical decision-making. In other words, your physician should not list HPI elements that are not relevant 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.