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Pediatric Coding Alert

Reader Questions:

3 or 4 HPI Elements Play Big Role in Final E/M Level

Published on Sun Jun 18, 2006

Question: How does a brief history of present illness (HPI) differ from an extended HPI?

Michigan Subscriber
 
Answer: You can distinguish between brief and extended HPIs based on the detail the pediatrician needs to accurately characterize the clinical problem(s). Specifically, a brief HPI consists of one to three elements, but an extended HPI includes four or more elements, according to the CMS 1995 Documentation Guidelines for Evaluation & Management Services
 
An extended HPI is necessary to reach a detailed history and thus the higher levels of E/M services. For instance, established patient office visit code 99214 requires a detailed history, which requires the pediatrician perform and document an extended HPI (four or more elements), extended review of systems (ROS) (two or more systems), and a pertinent past, family and/or social history (PFSH) (one of three).
 
For follow-up visits, documenting only three HPI elements will restrict you to 99213. On the hospital side, a brief HPI of three elements will land you with the lowest-level admission code, 99221 (Initial hospital care, per day, for the evaluation and management of a patient. ...).
 
The HPI is a chronological description of the patient's present illness from the first sign and/or symptom to the present. When counting HPI elements, look for these factors:
 

  • location -- what is the location of the problem?
     
  • quality -- what is the quality of the problem?
     
  • severity -- how intense is the pain?
     
  • duration -- how long has the patient had the problem?
     
  • timing -- is the problem better or worse at any time of the day?
     
  • context -- what is the patient's whole care setting?
     
  • modifying factors -- what can the patient do to alleviate or aggravate the pain?
     
  • associated signs and symptoms -- what other symptoms and signs does the patient have in relation to the chief complaint?

     -- Answers to You Be the Coder and Reader Questions reviewed/provided by Jim Collins, CPC, CHCC, president of Compliant MD Inc.; Victoria S. Jackson, practice management consultant with JCM Inc. in California; Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG -- Children's Healthcare of Atlanta at Egleston; and Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.

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