Pediatric Coding Alert

Question: One of our pediatricians is great at documenting the exam and medical decision-making, but struggles with coding History of Present Illness (HPI). Can you advise on why this is important so we can explain it to him?

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Answer: When you are poring over encounter notes looking for the portions of an E/M service your physician provided, be sure to focus on the patient’s history of present illness (HPI). This is the further description of the patient’s current condition or symptoms. During HPI, the physician will ask a series of questions to determine the best course of treatment.

There are two types of HPI: brief and extended. You cannot code for higher-level E/Ms without an extended HPI. Get to know how to spot each HPI element with this quick primer.

For coding purposes, CPT^® identifies seven possible HPI “elements:”

• Quality
• Severity
• Timing
• Context
• Modifying factors
• Associated signs and symptoms

Medicare and most private payers consider “duration” an eighth HPI element, even though CPT^® does not list it. If you are unsure of your payer’s policy on duration, check with it before filing the claim.

Definition: Duration is slightly different from timing in that a problem might be present for many days, but only occurs at night. Thus, the duration would be the number of days the condition is present and the timing would be at night.

If your pediatrician reviews and documents one to three of the HPI elements, then the HPI is brief. A brief HPI will support up to a 99202 for new patients, and a 99213 for established patients

When the provider reviews and documents patient findings for four elements or more, she has performed extended HPI. Depending on the other specifics of the encounter, an extended HPI could warrant a 99203 code or higher for new patients, and 99214-99215 for established patients.

Caveat: Extended HPI does not mean an automatic high-level E/M code. You cannot, however, report some higher-level E/Ms (new patient visits) without extended HPI. An established patient visit is billed based on two out of three key factors be present so although unlikely, a lesser history is possible and you may still be able to bill a higher level established patient visit.