Urology Coding Alert

Count carefully to reach the correct level code.

You know that HPI (history of present illness) is an important part of E/M coding. But when was the last time you delved into the specifics to be sure you were remembering everything? If it’s been a while, read on to refresh your memory on the documentation you need to fully support HPI choice – and correct E/M code assignment.

Focus on the ‘H’ of ‘History’

In most scenarios, the three key components used to select the level of E/M service are history, physical examination, and medical decision-making (MDM). HPI is one element within the history component, explains Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb. 

“Obtaining the patient’s HPI is an important first step in determining the etiology of a patient’s problem,” she says. “The HPI information can assist a practitioner in arriving at the patient’s diagnosis.”

Define it: CPT^® guidelines state that HPI is “a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem.”

Swanson says a provider usually starts the HPI conversation by asking the patient to describe his problem. This can include questions such as:

• What brings you to the office today? 
• How can we help you? 
• What seems to be the problem?

Basic Details Probably Means a Brief E/M

HPI is divided into two levels: brief and extended. You determine the correct HPI level by reviewing your provider’s notes and deciding how many of the following eight elements the provider reviewed relative to the patient’s chief complaint:

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

Know your payers: Medicare payers will consider all of the above HPI components. Some payers, however, don’t consider “duration” as a separate element because CPT^®  does not include it in its list of HPI components. Your payer representative can give you the latest information on how their carrier views HPI elements, including or not including the “duration” element.

Basic equals brief: When the provider performs a brief HPI, he/she will document one to three HPI components during the encounter. A brief HPI will support the following office visit E/M codes (assuming the rest of your documentation supports these codes), says Yvonne Bouvier CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind.:

• 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) or 99202 (… an expanded problem focused history; an expanded problem focused examination; straight­forward medical decision making) for new patients.
• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care profes­sional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) through 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) for established patients.

Documenting More HPI Elements Could Lead to Extended or Higher-Level E/M services

If the provider conducts and documents an extended HPI (four or more HPI elements) you might be able to report:

• 99203 (… a detailed history; a detailed examination; medical decision making of low complexity) through 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.

No assumptions: The extended HPI does not guarantee that you can report one of the above-listed E/M codes. The visit must meet other necessary elements as well. However, without an extended HPI, you may not be able to report any of the above higher-level E/M codes.

Example 1: For new patients (E/M codes 99201 to 99205), documenting one, two, or three HPI elements » will allow coding levels one and two (99201 and 99202) for the HPI portion of the history key component. Documenting four or more HPI elements for new patients will allow coding levels three to five (99203 to 99205) for the HPI.

Example 2: For established patients (E/M codes 99211 to 99215), documenting one, two, or three HPI elements will allow coding levels one to three (99211 to 99213) for the HPI portion of the history key component. Documenting four or more HPI elements for established patients will allow coding levels four to five (99214 and 99215) for the HPI.