By Dirk Elston, MD, September 03, 2012
I documented the location and symptoms of six distinct problems, but the auditor says I only documented two HPI elements. What gives?
The History of Present Illness (HPI) describes the development of the patient’s present illness in his or her own words. This is part of the history component of an Evaluation and Management (E/M) service (99201-99499). The Centers for Medicare and Medicaid Services (CMS) recognizes the following HPI elements:
- modifying factors, and
- associated signs and symptoms.
In Pennsylvania, Maryland, and Delaware, a favorable ruling by a Highmark Federal Services (now Novitas Solutions, Inc.) medical director allows counting individual HPI elements (such as symptoms) more than once when they relate to distinct presenting problems. (Note that the ruling indicates that merely listing the location of four separate lesions does not meet the criteria of an extended HPI.) [pagebreak]
Unfortunately, in much of the country, auditors have been directed to count HPI elements only once, even when the same element is appropriately documented for multiple distinct problems.
HPI elements are an essential component of the patient history, and part of the critical documentation of the pertinent facts, findings, and observations about a patient’s medical problems that allow for appropriate diagnosis and treatment. Appropriate documentation is meant to facilitate communication and continuity of care among physicians and other health care professionals, accurate and timely payment of claims, and quality-of-care evaluations. Only pertinent material should be documented, and irrelevant facts should never be added merely to increase the level of service. The medical record serves as a legal document to verify the care provided; hence, legibility becomes an essential requirement.
For coding purposes, the contribution of the HPI to the final level of service is distinguished by the number of elements needed to characterize the clinical issues accurately. A brief or problem-focused HPI contains one to three elements. An extended or comprehensive HPI contains four or more elements of the present illness or associated comorbidities. You may have to ask the patient about multiple discrete problems, each with signs, symptoms, or modifying factors, and it would be appropriate to document each of these. [pagebreak]
However, you should verify whether or not your local carrier allows elements to be counted more than once for distinct problems.
When using 1997 CMS guidelines, the status of three chronic or inactive conditions can be substituted for four elements of the HPI. However, the entire visit must then be coded using 1997 guidelines. According to CMS 1995 and 1997 E/M guidelines, the review of systems (ROS) and/or past, family, and social history (PFSH) may be recorded by ancillary staff or on a form completed by the patient; the same guidelines are silent as to who can record the HPI. Some carriers have issued policy statements that only the physician may record HPI elements. Currently, these carriers include WPS, Palmetto GBA, and Noridian. You should verify with your local Medicare carrier what its policy is regarding HPI documentation.
Unfair policies can be challenged at a regional level through claim appeals. Dermatologists are advised to review their local carrier policies for more specific E/M guidelines. [pagebreak]
Patient presents with an itchy (severity) and now sore due to scratching (context) rash on underarms (location) of four days (duration) with no help from an over-the-counter ointment (modifying factors).
You documented the severity, context, location, duration, and modifying factors related to the patient’s presenting condition. This qualifies as an extended or comprehensive HPI.
Patient presents with psoriasis, stable with the new medication; worsening eczema around the ears and neck since last visit; and warts on the left foot, previously treated cryogenically, that have spread.
You documented three chronic conditions. If you code the entire visit using the 1997 E/M guidelines, this qualifies as an extended or comprehensive HPI.
Patient presents with a tender papule on the right ear and an itchy patch on the left leg. No other historical elements are noted.
You documented the location and symptoms for two conditions; many local carriers direct their auditors to count HPI elements only once, even if documented for multiple distinct problems. This is unlikely to qualify as an extended HPI in most states.