Pediatric Coding Alert

Thinking of starting routine chart audits to decrease your practice's compliance risk? Use this guide to nail down chart notes' history of present illness (HPI) elements to ensure they support the selected code level.

For coding purposes, HPI is the chronological description of development of the present illness from first sign or symptom, or prior encounter, to present, explains Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. With HPI recording, the pediatrician should document the unique situation of each patient at each encounter to clearly substantiate the medical necessity of the service(s) rendered that day.

Depending on the payer, there are seven or eight HPI elements. For Medicaid payers, the HPI elements are:

• Location

• Quality

• Severity

• Duration

• Timing

• Context

• Modifying factors

• Associated signs and symptoms.

Heads up: CPT does not include duration in its list of HPI elements, so the AMA has seven elements. If you are unsure of a payers HPI element list, call your representative to check.

HPI is one of the three parts comprising an outpatient E/M services history component. There are two levels of HPI: brief and extended. A brief HPI consists of one to three elements, confirms Heather Smith, CPC, CMC, clinic coding/auditing coordinator for Michigan's South Haven Community Hospital.

For a new patient encounter, a brief HPI can support reporting up to 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...).

For established patients, a brief HPI can support up to 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 ...),

When the pediatrician's documentation satisfies four or more elements, she has performed an extended HPI, says Falbo.

The physician must achieve an extended HPI to document at least a detailed history -- meaning that an extended HPI is a requirement for all new patient E/Ms above 99202, and all established outpatient E/Ms beyond 99213 if the physician relies on history as one of the key components.

An extended HPI does not guarantee a higher-level E/M code, but it does make reporting it possible. The physician still has to satisfy other key elements of service before choosing these high-level codes.

Example: Notes indicate a patient reports to the pediatrician with a sore throat (location) and a productive cough (associated signs and symptoms). Patient reports Page 6 that her throat hurts worst at night (timing). She rates her throat pain as a 7 on a 10-point scale (severity). This is an extended HPI, as the physician described four elements in the notes. The documentation supports an established patient visit of greater than or equal to 99214 or a new patient visit code of greater than or equal to 99203, if the visit meets all other required elements as well.