History of the present illness

January 30th, 2015 - Codapedia Editor
Categories:   Audits/Auditing   Coding   Primary Care|Family Care  
0 Votes - Sign in to vote or comment.

Here are the elements of the HPI:

Location: Where do the patient's symptoms occur?  In order to use location, it should be a place on the body that you could point to or touch and that the physician describes as the place where the patient's symptoms occur.  Head, shoulders, knees and toes.

Quality:  What is the nature of the patient's symptoms? What is it like?  What characteristics describe the symptom?  Typically this will include colors, such as green, red, or yellowish.  It will include a description of the type of pain: burning, stabbing, dull, achy, etc.

Severity:  That is, how bad are the patient's symptoms?  Are they getting better or worse, increasing or decreasing?  Sometimes a clinician might note the pain scale that the patient is having, such as 9 of 10.  The patient might be feeling well or okay.

Duration: How long has the patient has these symptoms?  It could be short.  That is, the patient had them in the middle of last night, the symptoms have lasted for 24 hours, or it could be a longer time, such as longstanding, months, years.  Any description about the duration of the length of the patient's symptoms, illness or condition can be used as an element of duration.

Timing:  That is, under what circumstances do the symptom occur?  Is it intermittent, continuous, constant, upon awakening, still, or after exercising?  Those are the kinds of words, which can be used to describe the timing of a symptom.

Context:  In order to answer this question, consider in what context the patient's symptoms occur.  Did they happen after a motor vehicle accident, after slipping on the ice, or in relation to another illness or surgery?  

Modifying factors:  The modifying factors are any treatments prescribed by a physician or tried by the patient without physician direction, which the patient has used to try and improve their symptoms.  It could be that the patient has been on antibiotics already for a week, or that the patient has tried elevating their leg without relief, or that they have tried over-the-counter medications.  Aspirin, rest, antibiotics, CABG.

Associated signs and symptoms. That is, other findings that the patient presents with, related or unrelated to today's chief complaint.  It could be that the patient came in and also complained of fever, weakness, confusion--any other symptom, which the patient describes.  We typically think of these elements as positive complaints, but many auditors will use a negative response in associated signs and symptoms.

Can you use the same element twice?  The guidelines do not say yes or no about this. Some coding auditors report that in private communication CMS has told them that they can use the same element twice.  That is, they could use hip and leg, or hip and arm, as two elements if they were two different problems described in the HPI.  This is not verified in writing and it would be more conservative not to do that.  

Only the billing clinician may document the history of the present illness.  Unlike the chief complaint, review of systems, and past family medical and social history where a staff member might document part of the history as long as the physician has reviewed it, the history of the present illness must be documented by the billing provider.  

It is possible to use the status of three chronic diseases in place of the four elements of the history of the present illness.  This is especially helpful when treating patients with chronic problems such as diabetes, hypertension, and hyperlipidemia. In this case, specifically document the status of their problems at home in the history section.  Here is an example: “I am seeing this patient for follow-up for diabetes.  She reports her blood sugars at home to be in 150-200 range.  She is checking her sugars after meals.  Her current medication are X,Y and Z.”  Document the status of at least three of their chronic diseases in place of the four HPI elements.  Document one or the other.

It is insufficient to simply list their chronic diseases in the history and document the status in the assessment in the plan.  The status of their chronic diseases must be documented in the HPI.  

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain
July 17th, 2019 - Wyn Staheli, Director of Research
Now is the time to comment on a proposal to cover acupuncture for chronic low back pain. This comment period is the part of the HHS response to the opioid crisis. You only have until August 14th to officially comment.
Denial Management is Key to Profitability
July 15th, 2019 - Wyn Staheli, Director of Research
A recent article by Modern Medicine cited a report by Becker’s Hospital Review which stated that it costs approximately $118 per claim to resolve a claim denial. Granted, these were hospital claims, but the process is essentially the same for outpatient services. In fact, you could say it is...
Q/A: Do I Use 7th Character A for all Sprain/Strain Care Until MMI?
July 15th, 2019 - Wyn Staheli, Director of Research
Question: It is in regards to the Initial and Subsequent 7th digit (A and D) for sprains and strains. Recently, I have been told that I should continue with the A digit until the patient has reached Maximum Medical Improvement (MMI) and then switch over to the D place holder. Is ...
The Importance of Medical Necessity
July 9th, 2019 - Marge McQuade, CMSCS, CHCI, CPOM
ICD-10-CM codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the level of the E/M services provided. The issue of medical necessity is one of definitions and communication. What is obvious to the ...
When Can You Bill Orthosis Components Separately?
July 9th, 2019 - Wyn Staheli, Director of Research
Othoses often have extra components. When can you bill those components separately? For example, can you bill for a suspension sleeve (L2397) with a knee orthosis (e.g., L1810)?
Q/A: Can I Put the DC’s NPI in Item Number 24J for Massage Services?
July 8th, 2019 - Wyn Staheli, Director of Research
Question: Are there scenarios in which it is acceptable to put the DC's NPI in box 24j for massage services? Answer: While the answer to this is yes, it is essential to understand that there are very limited scenarios. In most cases, Item Number 24J is only for the NPI of the individual ...
Will the New Low Level Laser Therapy Code Solve Your Billing Issues?
July 8th, 2019 - Wyn Staheli, Director of Research
Low level laser therapy (LLLT), also known as cold laser therapy, is a form of phototherapy which uses a device that produces laser beam wavelengths, typically between 600 and 1000 nm and watts from 5–500 milliwatts (mW). It is often used to treat the following: Inflammatory conditions (e.g., Rheumatoid Arthritis, Carpal ...



About Codapedia by InnoviHealth Systems Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™ by InnoviHealth Systems™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association