Primary Care Coding Alert

Avoid the 1995/1997 guideline confusion once and for all.

Documenting the patient’s history of present illness (HPI) is fraught with coding challenges. Knowing what you can count, and what you can’t, can be critical to establishing the correct level of an evaluation and management (E/M) service.

And knowing how Centers for Medicare and Medicaid Services (CMS) regulations parallel, and deviate from, CPT^® guidelines, can be the source of great confusion.

So here are three great tips to help you determine your HPI levels with precision and simplify your E/M coding.

Tip 1: Learn the Elements and How They Add Up

First, let’s go back to Coding 101. HPI is regarded as one of three history elements (the others being a review of systems, or ROS, and the patient’s past, family, and/or social history, or PFSH) that determine the type of history taken. This, in turn, may help determine the level of E/M service provided to the patient.

The CPT^® manual defines HPI as “a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present” and goes on to identify seven individual HPI elements: “location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem(s).”

Coding alert: Though it does not appear in the CPT^® list, you can also count duration as an eighth HPI element. That’s because “CMS regards duration as an element of HPI,” according to Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. As “most auditors go by CMS in regard to HPI because they are the highest guideline out there, and as most carriers follow the guidelines put out by CMS,” you should count duration as an HPI element if your payer recognizes it, Holle suggests.

Adding it all up: There are two levels of HPI — brief and extended — that you determine by reviewing your provider’s notes and deciding how many of the eight elements the provider has reviewed relative to the patient’s chief complaint (CC). For a brief HPI, your documentation will need to include one to three of the above elements; for an extended HPI, the documentation needs to include four or more of the above elements.

Tip 2: Learn the Difference Between 1995 and 1997 Guidelines

So far, everything we’ve discussed pertains to the 1995 guidelines. The 1997 guidelines differ in one significant way, however. For an extended HPI, instead of documenting four or more HPI elements, you can substitute the status of three or more patient conditions, which may be chronic or inactive.

This suggests that the 1997 guidelines are better suited for follow-up visits with patients who have several chronic problems. Chronic conditions that are in remission or asymptomatic may not translate to HPI elements, and documenting patients with such illnesses using only the 1995 guidelines may not allow you to justify documenting and billing higher-level E/M services.

But whichever set of guidelines you decide to use, remember that you cannot use them interchangeably. Use one set of guidelines for each visit, but never combine them. And make sure you understand private payer preferences for these guidelines. While many payers will follow Medicare rules in this and other guideline choices, some may not.

(To view the 1995 guidelines, go to www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. And to view the 1997 guidelines, go to www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf).

Tip 3: Learn the Correct Way to Document HPI Elements

When you enter the HPI elements into your documentation, make sure that you don’t simply list the element on its own. “Just listing is not enough. Your provider needs to document the status of each condition for the condition to count,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Learn Who Can Document HPI

Like many of the guidelines surrounding HPI documentation, Medicare guidelines regarding who can document it are confusing. While CMS documentation guidelines for E/M services are clear that ancillary staff may document the ROS and PFSH components, they make no mention of who should document HPI, leaving Medicare contractors and some private payers to believe that “your provider has to obtain this portion of the history,” according to Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “In many offices, the clinical staff will list the chief complaint and maybe even a couple of statements. However, the provider will need to perform and document the HPI portion of the service for it to count in an audit,” Holle concludes.

Without changing its E/M documentation guidelines, CMS did take a step to liberalize who may document HPI beginning January 1, 2019. In the final rule on the 2019 Medicare Physician Fee Schedule, CMS stated that for both new and established patients, physicians no longer have to re-enter information in the medical record regarding the chief complaint and history (including the HPI) that either ancillary staff or the patient have already entered. A physician can choose to re-enter or bring forward information when documenting a visit. However, this is now optional.

In other words, you cannot simply say that your provider noted the location of the pain. Your provider will need to document the pain’s exact anatomical location in order to satisfy the location element of the HPI.

This is also true when you document other, non-HPI elements for HPI. For example, “if during the ROS portion of the exam, the provider documents ‘shortness of breath with chest pain,’ it would be appropriate to credit ‘shortness of breath’ in the ROS documentation ‘chest’ and as a location sign and symptom for the HPI,” says Falbo.

Again, payer guidelines may differ on documentation requirements, so it would be a good idea to seek clarification first about your payers’ rulings.

Putting it all together: Your provider sees an established patient who has injured his foot while running. The patient describes the pain as a 7 out of 10 on the pain scale. The patient also has a history of type 2 diabetes.

In this encounter, you can justify an extended HPI, as your provider reviewed four elements: location (foot), context (running), severity (pain level), and a modifying factor (patient history of type 2 diabetes).