Urology Coding Alert

Do You Remember the HPI Differences?

Quick – you report E/M codes on a regular basis for office visits, but do you remember the two types of HPI (history of present illness)? More importantly for your coding accuracy, do you remember how to distinguish between the two types?

Take two minutes to solidify your knowledge base.

Starting point: HPI is an element within the history component of a patient’s exam — one of the three key factors used in selecting the correct level of E/M service. The CPT^®  2017 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.”

In other words, the HPI gives details related to the patient’s chief complaint.

There are two levels of HPI — brief and extended. These HPI levels are distinguished by the amount of detail included in the documentation for the following elements:

• Location: The anatomical place/site of the chief complaint
• Quality: A detailed description of the problem
• Severity: The degree of intensity of the signs/symptoms
• Duration: Length of time of the complaint
• Timing: How often the symptoms occur
• Context: The circumstances/environment in which the symptoms occur
• Modifying factors: Anything that relieves or aggravates the problem
• Associated signs and symptoms:  Other related factors or symptoms.

With a brief HPI, the physician’s documentation would illustrate one to three of the elements listed above. With the documentation includes four or more elements, you have enough support for an extended HPI.

Important: Medicare considers all of the above HPI elements. Some other payers, however, may not count “duration” because CPT® does not include it in the list of HPI components. If you are unsure of a payer’s HPI element list, call your payer representative.