Pediatric Coding Alert

Hint: Simple signs like wet diapers might point to ROS, not HPI.

Multi-symptoms patients can be the top order of your day, so learn to analyze the charts and count correctly to reach the correct HPI (history of present illness) 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.

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 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.

"I suggest that coders have a template on hand to follow," says Debra Duguid, CPC, CEC, a coding reimbursement analyst for the division of pediatric hospital medicine at the University of Florida in Gainesville. When faced with prospective audits that weren't part of her normal assignments, Duguid asked the compliance office for a copy of the form they use so she could base her assessments on the same form.

When you count elements, check to see how many of these eight questions the physician answers in her 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)

Note: CPT does not include "duration" in its list of HPI elements, so has seven instead of eight. 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 scenarios recently shared on the Pediatric Coding Listserv at https://www.aapc.com/codes/.

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).

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.

"I would not consider the two wet diapers as 'timing' but more a review of systems," explains Donelle Holle, RN, a consultant with Pedscoding.com in Indiana. However, some coders might consider the wet diapers a way to check the severity of illness (two wet diapers show the child is not dehydrated). Remember that if you count the diapers toward your ROS you can't include it in your HPI 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.

Remember to Keep Totals Current

"Doctors need to realize the documentation must stand for itself each day," Duguid says. "In other words, if the patient is in-house for several days, you don'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."

Early catch: Duguid also recommends establishing a system for checking charts and supplying feedback. "Review any new doctor's work early and often," she says. "That way bad habit can be caught and corrected when they first begin."