ED Coding and Reimbursement Alert

Note slight differences in HPI rules among payers.

Coders that cannot identify history of present illness (HPI) elements on ED encounter forms could be miscoding many E/M claims.

Why? HPI elements are integral when selecting the appropriate ED E/M level (99281-99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: ...).

Avoid over- and undercoding your ED E/M encounters with this expert input on selecting HPI levels.

HPI Follows Chief Complaint in Most Visits

"The HPI is a chronological description of the development of the patient's present illness or injury, starting from the first sign and symptom up until the patient presents for medical care," explains Judy Newberry LPN, CPC, CCS-P, medical coding director for Insurance-Data Services in Wyoming, Mich. After the physician discovers the patient's chief complaint[s], the next step is determining the HPI, relays Peggy Bryant, CPC, CCP, professional coding audit coordinator with Dickinson County Healthcare System in Iron Mountain, Mich. "It [HPI] sets the stage for possible diagnoses, and enables the provider to obtain additional details relating to the chief complaint," she says.

Benefit: HPI helps the physician more adequately determine the type of examination and medical decision making (MDM) she'll need to make. "HPI also assists in deciding what, if any, diagnostic testing will be needed," says Bryant.

Here's Why Getting HPI Wrong Could Cost You

There are two HPI levels: brief and extended: "A brief HPI can consist of one to three [HPI] elements," explains Tracey Koch, CCS-P, ER client support coding and education manager at Comprehensive Medical Management in Newport, Ky. Brief HPI can support up to a level-three ED E/M (99283, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...), Koch confirms.

An extended HPI, however, requires at least four HPI elements, Bryant says. Extended HPI can support up to a level-five ED E/M (99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...).

Extended HPI does not guarantee a level-four or -- five ED E/M code, though it does make reporting these codes possible. Before choosing 99284 (... a detailed history; a detailed examination; and medical decision making of moderate complexity ...) or 99285, make sure other encounter specifics meet the parameters of these codes.

Best bet: Get to know your HPI levels by flawlessly recognizing all HPI elements.

Use 8 HPI Elements -- or 7

You'll need to observe slightly different rules for different payers on the number of potential HPI elements per ED E/M encounter, reminds Koch.

Medicare: Medicare payers, and payers that adhere to Medicare rules, count eight HPI elements:

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

Private payers: Payers that observe CPT rules fold timing into duration, meaning you have only seven elements to select from for these carriers.

Medicare's "description of timing is the time of day the patient experienced the signs and symptoms ... duration is how long the patient's signs and symptoms have been present," Koch relays.

Check Out These Clinical Examples

Here are a pair of scenarios that illustrate the difference between brief and extended HPI:

Example 1: A patient presents to the ED complaining of a severe headache. The ED physician asks the patient if the pain is acute in a single area of the head, and she says it's "mostly behind my right eye." The physician then asks the patient to describe the pain ("it's sharp") and assign it a number on a 1-10 scale (8).

This is a brief HPI. During the encounter, the physician inquired about three HPI elements (location, quality, severity). Now take a look at this extended HPI scenario, courtesy of Bryant:

Example 2: A 50-year-old female patient with a past history of hernias reports to the ED with a chief complaint of abdominal pain. The physician discovers that the patient has had two hernia repairs previously, the most recent two years ago. She reports abdominal pain in the umbilical area and upper epigastric area (1, location) for the past two or three days (2, duration).

The patient says that the pain "is "getting worse" (3, severity). Notes indicate that the pain was "sharp, non-radiating" (4, quality), and increased when the patient was sitting up (5, modifying factor). The patient says she has not experienced nausea or vomiting (6, associated signs/symptoms) along with the pain. In this instance, the physician addressed six HPI elements.

-- Articles reviewed by Michael A. Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass.