Ophthalmology and Optometry Coding Alert

Question: One area where our physicians don't document well enough is history of present illness (HPI). Do you have any tips so we can help them document this better?

Codify Subscriber

Answer: The guidelines are both lengthy and complex. So, it's no wonder that there is confusion surrounding HPI and the role it plays in reporting E/M services. HPI is an element within the history component - one of the three key factors used in selecting the correct level of E/M service. The CPT® manual defines HPI as "a chronological description of the development of the patient's present illness from the first sign and/or symptom to the present" and goes on to identify eight individual HPI elements.

Fun fact: You can remember those elements using the mnemonic SOCRATES.

• Site (Location): The anatomical place or site of the chief complaint.
• Onset (Duration): Length of time of the complaint.
• Context: The circumstances/environment in which the symptoms occur.
• Radiation (Quality): How the complaint feels (stabbing, achy, itchy, better, worse, etc.).
• Associated signs and symptoms: Other related factors or symptoms, positive or negative.
• Timing: How often the symptoms occur (frequently, occasionally, etc.).
• Exacerbating/Alleviating (Modifying factors): Anything that relieves or aggravates the problem.
• Severity: The degree of intensity of the signs or symptoms (1-10 pain scale, wincing, doubled over in pain, etc.).

There are two levels of HPI - brief and extended. Per both the 1995 and 1997 guidelines, you tally HPI by reviewing the notes and deciding how many of the above eight elements the provider has reviewed relative to the patient's chief complaint (CC).

For a brief, problem-focused, or expanded problem-focused HPI the documentation needs to include one to three of the above elements.

For an extended, detailed, or comprehensive HPI the documentation needs to include four or more of the above elements.