Pediatric Coding Alert

Take this step toward fixing your E/M documentation.

If you’re planning to tighten up your practice’s E/M coding (as advised in our cover story), the history of present illness (HPI) is a good place to start. Multi-symptom patients can be the top order of your day, so learn to analyze the charts and count correctly to reach the correct HPI level.

Here’s why: You count HPI (history of present illness) elements for each case because they’re an important part of the history component of E/M services. A “brief” HPI consists of one to three elements, and an “extended” HPI requires four or more elements as described below. 

Having enough elements to qualify as an extended HPI means the care might qualify for a detailed or comprehensive history. Documenting an extended HPI makes reporting a higher E/M code possible, but does not guarantee that step. The physician still must satisfy the review of systems (ROS) and past, family social history (PFSH), as well as the other major elements of service (physical exam and medical decision-making).

Tally These Elements of Patient’s Condition

For coding purposes, HPI is an ordered description of the patient’s current condition. Many practices use a template to keep track of which elements go toward the HPI, which are location, quality, severity, duration, timing, context, modifying factors and the associated signs and symptoms reported by the patient. When you count elements, check to see how many of these eight questions are documented in the notes.

1.What is the physical location of the problem on or in the body? (Location)
2.How is the symptom further described, related to the type of pain? (Quality)
3.How intense is the problem or related pain? (Severity)
4.How long has the patient had the problem? (Duration)
5.Is the problem better or worse at any time of the day? (Timing)
6.How did the injury occur? (Context)
7.What can the patient do (or what has the patient done) to alleviate or aggravate the pain? (Modifying factors)
8.What other symptoms and signs does the patient have in relation to the chief complaint? (Associated signs and symptoms)

Check How Elements Come Together 

Now that you’ve refreshed your memory on how to count HPI elements, put your knowledge to the test with these common pediatric scenarios.

Patient 1: A father brings his three-year-old son who has a cough, cold, running nose, and sore throat. His ears do not hurt. Symptoms started two nights ago and the child’s temperature reached 101F last night.

Chief complaint: Cough

HPI count: Duration (2 nights); associated signs and symptoms (runny nose and sore throat); timing (fever last night)

Review of systems (ROS): ENT and constitutional.

You’ve documented a brief HPI with three elements (duration, associated signs and symptoms, and timing).

PFSH: Not addressed

Patient 2: An 8-month-old baby has a fever and cough; the cough and rhinorrhea began four days ago. His mother says he is not eating and is not drinking as much as usual, though he had two wet diapers before coming to your office. His older siblings have cold symptoms.

Chief complaint: Fever and cough

HPI count: Duration (4 days); associated signs and symptoms (not eating or drinking as much)

ROS: GI.

PFSH: Siblings have a cold.

Depending on the pediatrician’s opinion, you may be able to count the two wet diapers as a way to check the severity of illness (showing that the child is not dehydrated, since he isn’t drinking as much as usual). Remember that if you count the diapers toward your HPI you can’t include it in your review of systems element count.

Either way, you have another brief HPI with two or three documented elements (duration, associated signs and symptoms, and possibly severity).

E/M choice: The documentation for both patients is consistent with the HPI elements required to report a mid-level E/M code. Choose 99202 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) as appropriate. You must document four HPI elements before qualifying for 99214. This would also require two or more elements of the ROS and one element of PFSH, as well as appropriate exam and/or MDM.

Remember to Keep Totals Current

Keep in mind that your documentation must stand for itself each day. If the patient is in the hospital for several days or visits your office several days in a row, you can’t count the HPI listed in yesterday’s documentation for today. If you want it counted for today, you must repeat the information each day.