Cardiology Coding Alert

Don't let counting duration drag you into error territory.

To succeed at E/M coding, you have to master all the individual pieces that add up to an E/M level. One of those pieces is history of present illness, also known as HPI.

Getting HPI too high puts you at risk of overcoding and exposing your practice to auditors. Getting HPI too low could result in undercoding your E/M services, which will cost the practice money (and draw auditors' attention, too).

Help's here: Use these two case studies to illustrate brief and extended HPIs, and tallying HPI levels will be a breeze.

First: Line Up Element List by Payer

Depending on the payer, there are seven or eight HPI elements, says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

For Medicare and Medicaid payers, the HPI elements are:

1. Location
2. Quality
3. Severity
4. Duration
5. Timing
6. Context
7. Modifying factors
8. Associated signs and symptoms.

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

Case Study 1: Brief HPI

When a provider reviews one to three elements during the E/M, she is performing a brief HPI, says Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb. The systems the provider reviews should be documented for the substantiation of a brief HPI.

Scenario: A Medicare patient reports to the cardiologist with a chief compliant of chest pain (location). The patient reports that the pain has been coming and going for about a month (duration).

HPI: The provider documented two elements, so this case is an example of brief HPI.

Case Study 2: Extended HPI

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

Scenario: A Medicare patient reports complaining of chest pain. Based on the presentation, the provider gathers this information from the patient:

1. Where the pain is centered (location)
2. How long he has had the pain (duration)
3. How he would describe the pain (quality)
4. How bad the pain is on a scale of 1-10 (severity)
5. If the pain is worse in the evening (timing)
6. If he has had any swelling, leg pain, fever, cough, or other symptoms (associated signs and symptoms)
7. If he has taken any pain relievers to deal with the pain (modifying factors).

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