Pediatric Coding Alert

Question: An established patient reports to the pediatrician with a chief complaint of abdominal pain. Notes indicate that the pediatrician asked the patient the location of the pain, how severe the pain is, how long the pain has lasted, and whether the pain is accompanied by any other issues. Which level of history of present illness (HPI) is this encounter?

Arkansas Subscriber

Answer: It depends on the insurer’s policy, as your encounter lies right on the line between two HPI levels.

The rules: CPT^® lists seven elements on its HPI list: location, quality, severity, timing, context, modifying factors, associated signs and symptoms), but Medicare includes duration as an eighth element. Depending on which rules the payer follows, your pediatrician reviewed three or four HPI; four for a Medicare payer, and three for a payer that’s governed by CPT^® guidelines.

Your claim: If you’re reporting the claim to a Medicare-observant payer, your pediatrician performed an extended HPI. Conversely, if you’re reporting the claim for a patient insured by private payers, it might consider the pediatrician’s actions brief HPI.

The good news, however, is that most auditors go by the auditing rules put forth by Medicare as a guideline for HPI. Just make sure that the payer’s observing Medicare HPI rules before coding.

Why it matters: CPT^® rules dictate that brief HPI can only be part of problem-focused or expanded problem-focused history; therefore, brief HPI can only support a lower-level E/M code.

If you’ve got an extended HPI, it might mean that you can code for a detailed or comprehensive history; therefore, extended HPI can support higher-level office visit E/Ms.

Remember: An extended HPI does not guarantee a higher-level E/M code; it only makes reporting these E/M codes possible.

Warning: Payers are always on the lookout for artificially inflated HPI levels on claims, as they can affect the level of evaluation and management (E/M) service you code. The physician should only cover HPI elements that are relevant to the chief complaint. Listing irrelevant HPI elements to increase levels could raise red flags with payers.