Neurosurgery Coding Alert

Question: The patient complains of a shooting pain down their cervical spine for the past three months. What factors need to be documented in order to reach an extended history of present illness (HPI)?

Colorado Subscriber

Answer: There is a total of eight different elements that you may account for when determining the level of HPI:

• Location:  The anatomical place or site of the chief complaint; in this case, "pain down cervical spine."
• Quality: Further description of the problem (stabbing, achy, itchy, etc.); in this case, "shooting pain."
• Duration: Length of time of the complaint; in this case "for the past 3 months."
• Severity: The degree of intensity of the signs or symptoms.
• Timing: How often/when the symptoms occur.
• Context: The circumstances/environment in which the symptoms occur.
• Modifying factors: Anything that relieves or aggravates the problem.
• Associated signs and symptoms: Other related factors or symptoms.

You will determine the patient's level of HPI by determining which of these elements the documentation accounts for. If you are only able to document one to three of these elements, you will reach a level of brief HPI. To reach an extended HPI level, you or your provider will need to document four or more of the above elements.

In this case, the documentation only supports three HPI elements. Had the provider documented one more, such as "ibuprofen helps reduce the pain" (Modifying factors), "the pain is a 7 on a scale of 10" (Severity), or "the pain is usually worse at night" (Timing), the fourth HPI element would have qualified the note as an extended HPI.

Remember: Some payers don't consider duration as a separate element, as CPT® does not include it in its list of HPI components. If you are unsure of a payer's HPI element list, call your representative to check and then document the response.