EM Coding Alert

Remember, Medicare, and CPT^® differ on duration element.

Each coder in the office needs to know the difference between brief and extended history of present illness (HPI) levels. If they don’t, they can’t be expected to choose the correct E/M level for each office E/M visit they code.

Fallout: Get HPI too high, and you’ll be overcoding and exposing your practice to auditors. Get HPI too low, and you’ll be undercoding your E/M services, which will cost the practice money.

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, reminds 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:

• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• 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, confirms 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 reviewed 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.

Consider this example from Bucknam:

Scenario: A Medicare patient reports complaining of a headache. The provider asks the patient:

• where the pain is centered (location);
• how long he has had the headache (duration);
• how he would describe the pain (quality);
• how bad the pain is on a scale of 1-10 (severity);
• if the pain is worse in the evening or when he’s been reading a lot (timing)
• if he has had any ear pain, stuffy head, sore throat, fever, or other symptoms (associated signs and symptoms); and
• 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.