Primary Care Coding Alert

Not accurately counting history of present illness (HPI) elements can land you on lower-level E/M codes, which could cost your practice deserved payment.

Solution: Use this guide to nail down chart notes HPI elements.

Count These HPI Items

For coding purposes, HPI is the chronological description of development of the present illness from first sign or symptom, or prior encounter, to present, explains Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Depending on the payer, there are seven or eight HPI elements. For Medicare and Medicaid payers, the HPI elements are:

" Location

" Quality

" Severity

" Duration

" Timing

" Context

" Modifying factors

" Associated signs and symptoms.

Heads up: CPT does not include duration in its list of HPI elements, so the AMA has seven elements. If you are unsure of a payers HPI element list, call your representative to check.

Stay Below 99203 With Brief HPI

HPI is one of the three parts comprising an outpatient E/M services history component. There are two levels of HPI: brief and extended. A brief HPI consists of one to three elements, confirms Heather Smith, CPC, CMC, clinic coding/auditing coordinator for Michigans South Haven Community Hospital.

For a new-patient encounter, a brief HPI can support up to 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making &).

For established patients, a brief HPI can support up to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity &), Smith says.

Example: A teenager presents with abdominal pain (location) associated with nausea and vomiting (signs and symptoms). He says that the pain is worse in the morning (timing). This note reflects a brief HPI.

Exceed 3 Elements for Extended HPI

When the FP satisfies four or more elements, she has performed an extended HPI, says Falbo. The physician must achieve an extended HPI to document at least a detailed history -- meaning that extended HPI is a requirement for all new patient E/Ms above 99202; and all established outpatient E/Ms beyond 99213 if they rely on history as one of the key components.

Extended HPI does not guarantee a higher-level E/M code, but it does make reporting it possible. The physician still has to satisfy other elements of service before choosing these high-level codes.

Example: Notes indicate a patient reports to the FP with a sore throat (location) and a productive cough (associated signs and symptoms). Patient reports that her throat hurts worst at night (timing). She rates her throat pain as a 7 on a 10-point scale (severity). This is an extended HPI, as the physician described four elements in the notes.

Determine Type Using These Questions

When counting elements, check to see how many of these eight questions the physician answers in the notes:

" What is the location of the problem? (location)

" What is the quality of the problem? (quality)

" How intense is the pain or problem? (severity)

" How long has the patient had the problem? (duration)

" Is the problem better or worse at any time of the day? (timing)

" What is the setting or circumstances in which the problem occurs? (context)

" What can the patient do to alleviate or aggravate the problem? (modifying factors)

" What other symptoms and signs does the patient have in relation to the chief complaint? (associated signs and symptoms)

Note: Payers that follow CPT guidelines wont accept duration as an HPI element, so dont include it in your HPI count for those claims.

Caution: If the FP just checks off the questions he asked the patient, ask him for encounter details to ensure proper HPI level. With HPI recording, the FP should document the unique situation of each patient at each encounter to clearly substantiate the medical necessity of the service(s) rendered that day, explains Falbo.