General Surgery Coding Alert

Question: A patient came to the surgeon's office complaining of severe abdominal pain. The surgeon had performed two previous hernia repairs for the patient. The patient says the pain is occurring mostly in her umbilical and upper epigastric areas. Notes indicate that the sharp and nonradiating pains have been occurring "off and on" for two or three days; further the pains are getting worse each day. The notes also read that the pain gets worse when she sits up, but she reports no nausea or vomiting. What level history of present illness (HPI) is this encounter?

Tennessee Subscriber

Answer: This is an extended HPI, as the physician noted seven HPI elements:

• Location (pain in upper epigastric, umbilical areas)
• Duration (pain has gone on for two or three days)
• Severity (pain gets worse each day)
• Timing (pain occurs "off and on")
• Quality (pain is sharp, non-radiating)
• Modifying factors (pain increases in seated position)
• Associated signs and symptoms (patient experiences no nausea or vomiting).

Breakdown: There are two types of HPI: brief and extended. A brief HPI occurs when the provider lists three or fewer HPI elements; payers consider four or more elements extended HPI.

An extended HPI can support up to a level-five E/M outpatient service (99215, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...).

Beware: Extended HPI does not, however, guarantee a high-level office E/M code for an established patient. Be sure to consider all three components of an E/M service when choosing the appropriate level code (99211-99215).