Beware of CPT® and Medicare differences when counting HPI elements.

Not accurately accounting for the history of presentillness (HPI) documented by your oncologist could result in missing appropriate opportunities to report level 4 or 5 E/M visits. Ensure you’re not missing higher paying possibilities by reviewing this guide to capturing HPI elements.

Brush Up on What Qualifies as an HPI Element

HPI is one of the three parts comprising an outpatient E/M history. It describes the patient’s present illness or problem, from the first sign/symptom to the current status, and typically drives a provider’s decisions about the physical examination and treatment. “The information gathered during the physical exam (PE) portion of a patient’s evaluation often only shows a very limited picture of the patient’s problem. However, speaking with a patient and gathering the history of the patient’s problem” can help fill out the picture, explains Amanda S. Stoltman, CCS-P, compliance coder at Urology Associates in Muncie, Ind.

 Start counting:

HPI also will often determine the level of service you’ll report. You’ll count the HPI elements to help you determine which level of service you can report. There are seven or eight HPI elements, depending on which source you are following. For Medicare, the eight elements are as follows: 

• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associated signs and symptoms.

Medicare includes the above list in both the 1995 and 1997 E/M Documentation Guidelines, available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

In contrast: CPT® lists only seven HPI elements in the E/M Services Guidelines, with duration not making the list. Therefore, for Medicare and payers following its guidelines, you should consider duration and timing separately. With payers that follow AMA rules, however, be aware that they don’t consider duration and timing to be two separate elements. Rumor has it...