Pulmonology Coding Alert
Avoid These Common HPI Issues to Pinpoint the Most Accurate History Level
Selecting between the two HPI levels isn’t like flipping a coin. Although your practice is heading toward using a new E/M coding system in January, you’ve still got a few months to go before the 2021 guidelines kick in. Plus, accurate coding when 2021 starts can only happen if your documentation remains just as thorough as it has to be right now, and services other than outpatient/office visits will still require the current elements next year. Therefore, it’s a good idea to refresh your mind on what’s required from a documentation standpoint so you can continue coding accurately. One area that tends to trip up even the most seasoned pulmonology coders is the history of present illness (HPI). HPI is an element within the history component — one of the three key factors used in selecting the correct level of E/M service. The CPT® code book 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 eight individual HPI elements. Fun fact: You can remember those elements using the mnemonic SOCRATES. There are two levels of HPI: brief and extended. For a brief, problem-focused, or expanded problem-focused HPI, the documentation needs to include one to three of the above elements. For an extended, detailed, or comprehensive HPI, the documentation needs to include four or more of the above elements. The 1997 E/M Documentation Guidelines also allow the provider to document the status of three or more chronic conditions, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. Unfortunately, coding HPI from an actual pulmonology encounter note isn’t always as simple as reading through the history and finding the required elements. In many cases, coders face confusion and stress when trying to pinpoint the best HPI level. Check out the following commonly held myths to ensure that you’ve got a handle on accurate HPI coding. Myth 1: Just Listing the HPI Element or Chronic Condition Is Sufficient Not so, Pohlig says. Just listing is not enough. Your provider needs to document the status of each condition for the condition to count. For example, she advises, it might say, “Since the last visit, patient’s asthma has been well controlled on maintenance medication without need for rescue inhaler or nebulizer.” Equal attention is required when choosing to document the HPI elements, Pohlig says. For instance, you cannot simply check off “Evaluated site, timing, and severity of the patient’s breathing issue.” You should instead get detailed, saying, “The patient feels a crackling sensation in the lower part of his chest when he breathes, which happens at least twice per hour. The crackling causes a discomfort that reaches an 8 on the 1-10 pain scale.” Myth 2: Duration Is Not Regarded as an HPI Element Technically, this is true. The CPT® guidelines state that HPI should include “a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms.” The list contains no mention of onset or duration. However, CMS does recognize duration as a separate element of HPI. Most auditors go by CMS standards in regard to HPI because they are the highest guideline out there. All Medicare contractors and most other carriers follow the guidelines put out by CMS. Remember: If you are unsure of a payer’s HPI element list, you can check your contractual agreement, which should identify the recognized guidelines, Pohlig says. “If not mentioned, you can call your representative to check, and then document the response.” Myth 3: You Can’t Count Non-HPI -Located Elements for HPI Actually, this is permissible, provided it is done in the right way. Pohlig offers the following example: The patient presents with respiratory complaints, and during the review of systems (ROS) portion of the intake, the provider also documents “shortness of breath with chest pain.” In this case, it would be appropriate to credit “shortness of breath” in the ROS documentation and as a sign and symptom for the HPI. This can be a source of significant coding confusion. Stating a cough is in the lungs is not specifying location, but stating having chest pain under the ribs when coughing would be location. Once again, however, individual payers’ guidelines may differ, so it would be a good idea to seek clarification from them first about their ruling. Myth 4: You Can Document Chronic Conditions Instead of HPI This is where the 1995 and 1997 Documentation Guidelines get muddied. If you are using the 1995 guidelines, documenting chronic conditions is not acceptable. Under 1997 guidelines, however, you can use status of one or two chronic medical problems instead of one to three HPI elements for a brief problem-focused or expanded problem-focused HPI, and status of three chronic medical problems instead of four HPI elements for an extended, detailed, or comprehensive HPI. The golden rule? Your provider has to obtain this portion of the history. In many offices, the clinical staff will list the chief complaint and maybe even a couple statements. However, the provider will need to perform and document the HPI portion of the service for it to count in an audit.
Pulmonology Coding Alert
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Avoid These Common HPI Issues to Pinpoint the Most Accurate History Level
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