Pulmonology Coding Alert

Question: I am having some trouble understanding the elements of history of present illness (HPI) as they relate to the 1995 documentation guidelines. What exactly are the HPI elements, and why do coders have to count them?

Idaho Subscriber

Answer: You need to count the HPI elements because they are an important part of the history component of E/M services. A brief HPI consists of one to three elements, whereas extended HPI requires four-plus elements. The physician must perform an extended HPI in order to satisfy the requirements for a detailed or comprehensive history. Extended HPI does not guarantee that you can report high-level E/M codes, but it does make reporting them possible. The physician still has to satisfy the other elements of the service before choosing high-level codes.

Checklist: For coding purposes, HPI is an ordered description of the patient's current malady. When counting elements, check to see how many of these eight questions the physician answers in the 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 (such as crampy or sharp)? (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 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 it has seven elements. In contrast, CMS documentation guidelines do acknowledge all eight.

Example: Notes indicate a patient reports to the office complaining of left-sided sore throat (location) and wheezing (associated signs and symptoms) for the past two days (duration). He rates his pain as moderate (severity). Patient reports that the wheezing is worse at night (timing).

This is an extended HPI, as the physician noted five elements in the notes.