Pulmonology Coding Alert

Knowledge of history of present illness is essential when coding these charts.

When pulmonologists evaluate patients, they must consider the symptoms, how long the patient has felt sick, the severity of the symptoms and other facts before pinpointing a diagnosis. The same goes for coders, who have to consider these factors as well, so they can select an appropriate E/M code.

These factors, which make up the history of present illness (HPI), can sometimes be a challenge to coders, but they’re an essential part of determining the E/M level. The following guide can help you get the full lowdown on which elements to apply and when to apply them.

Identify HPI Definition

HPI is a “chronological description of the development and/or progress of the patient’s present illness/injury,” explains Yvonne Dillon, CPC, CEDC of Bill Dunbar and Associates, LLC, in Indianapolis, Ind. Providers take HPI when interviewing the patient about the condition that caused them to visit the practice.

The provider should get the description from the patient’s own words during the encounter “from the first sign and/or symptom, or from the previous encounter, to the present visit,” explains Dillon.

Check Which Element List You Should Use

Depending on the payer, there are seven or eight HPI elements, reminds Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. For Medicare and Medicaid payers, the HPI elements are:

• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associated signs and symptoms.

Caveat:  CPT^® does not include duration in its list of HPI elements, so some private payers might only use the other seven elements. If you are unsure of a payer’s HPI element list, call your representative to check.

Use 3-Element Limit for Brief HPI

Once you’ve got a handle on what HPI is, and which element list you’ll use, you’re ready to check the encounter notes to see whether the provider performed brief or extended HPI.

When a provider reviews one to three elements during the E/M, she is performing brief HPI, confirms Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska.

Because CPT^® considers a brief HPI part of a problem-focused or expanded problem-focused history, it can support the following E/M office visit levels, among others:

• »99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straight­forward medical decision making…) and 99202 (… an expanded problem focused history; an expanded problem focused examination; straight­forward medical decision making …) for new patients.
• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …) and 99213 (… an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) for established patients.

Scenario: A Medicare patient reports to the pulmonologist with a chief compliant of chest pain on the left side (location) when coughing (context). The patient reports that the pain has gone on for about a month (duration).

HPI: The provider reviewed three elements, so this is an example of a brief HPI.

Count to 4 Before Considering Extended HPI

When a provider reviews four or more elements during the E/M, she is performing an extended HPI, Swanson says.

Having enough elements to qualify as an extended HPI means the care might mean coding for a detailed or comprehensive history. When you spot an extended HPI on an encounter form, it might make the visit eligible for the following E/M office visit levels:

• 99203 (… a detailed history; a detailed examination; medical decision making of low complexity…), 99204 (… a comprehensive history; a comprehensive examination; medical decision making of moderate complexity …) and 99205 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity …) for new patients
• 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity …) and 99215 (… a comprehensive history; a compre­hensive examination; medical decision making of high complexity …) for established patients.

Remember: An extended HPI does not guarantee a higher-level E/M code; it only makes reporting these E/M codes possible. The provider must still satisfy other encounter requirements (review of systems [ROS] level; past, family, social history [PFSH] level; physical exam level; medical decision-making level) in order to select a higher-level E/M office visit code.

Consider this example

A Medicare patient reports to your office complaining of pain in his chest when he coughs or inhales deeply. The provider asks the patient:

• where the pain is centered (location);
• how long he has had the pain (duration);
• how he would describe the pain (quality);
• how bad the pain is on a scale of 1-10 (severity);
• if the pain is worse in the evening or when he’s been moving/walking a lot (timing)
• if he has any pain in his back, throat, or shoulders (associated signs and symptoms); and
• if he has taken any pain relievers or other over-the-counter medications to deal with the pain (modifying factors).

HPI:  The provider reviewed seven factors, so this case is an example of extended HPI.