Pulmonology Coding Alert

Question: An internal chart audit of our evaluation and management (E/M) claims showed that our history of present illness (HPI) levels lessened the rightful service level of some claims. Can you offer tips on getting the most accurate HPI level possible for each E/M?


North Dakota Subscriber
Answer: Getting a full picture of a patient's medical history is a difficult challenge, but one you can meet.

Check out this review of the elements that go toward determining HPI in a patient with chest pain:

Location is the place on the patient's body where the chest pain occurred (e.g. "in the right chest .")

Context is what the patient was doing when the chest pain  occurred (e.g. "patient had chest pain while climbing stairs.")

Quality describes the chief complaint or sign or symptoms. So if a patient reports with a dull pain in the chest, "dull" is the quality.

Timing is the time of day the patient experienced the signs and symptoms. If the notes read "mild chest pain at night, last two weeks," "at night" is the timing.

Severity shows just how serious the patient's condition is. Physicians often show severity in their notes via a scale of 1 (least painful) to 10 (most painful).

Duration is how long the patient's signs and symptoms have been present. (e.g. "Patient has had symptoms for the last four hours.")

Modifying factors are things the patient did herself to alleviate the pain, as well as the things the patient did to make the symptoms worse.
 
For example, "Patient's chest pain was worsened by his pacing around the room," "Chest pain improved when patient sat down and breathed deeply.")

Associated signs and symptoms are any other problems the patient has in addition to the chief complaint. (e.g. an anxiety attack or shortness of breath may accompany a patient's chest pain.)