Coding & Reimbursement

History of Present Illness

By Suzanne L. Corcoran, COE

The medical history is an important factor in documenting an exam. It consists of three elements: review of systems (ROS), history of present illness (HPI) and past personal, family and social history (PFSH). This month we address the HPI as one critical element of the medical history.

Q. What is the HPI and how is it different from the chief complaint (CC)?

The HPI is one element of the patient's medical history. The evaluation and management (E/M) guidelines define the HPI as "a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present."

The CC and the HPI are closely related. The CC states why the patient is in the office. It is a brief description of the reason for that day's visit, including symptoms, problems, abnormalities, chronic disease(s) or other explanation. It is generally stated in the patient's own words. The HPI expands on the patient's CC with a series of descriptors.

Q. What constitutes an HPI?

A brief HPI contains one to three descriptors, each one from a different category. An extended HPI contains four descriptors or the status of at least three chronic conditions.

The components of the HPI include: location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms. For example, a patient presents with an HPI of "Cataracts OU, slow decrease in vision during past 6 months, trouble reading." The components of the HPI are: quality (decreased vision secondary to cataract), location (OU), duration (6 months) and associated signs (trouble reading).

Q. May a technician perform the HPI?

No. Two Medicare carriers, Palmetto GBA and Noridian, published information regarding who may perform the HPI. Noridian writes: "… E/M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when 'physician' criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e., registered nurse, licensed practical nurse, medical assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it." Palmetto GBA cites CMS as the authority for its position that "Only the physician who is conducting the E/M visit can perform the HPI."

A scribe may record the HPI dictated by the physician. Noridian also writes: "The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name."

The notes for the CC and HPI should be separated. The handwriting need not be the physician's. However, an attestation is needed for the HPI to indicate that it was performed by a physician. The attestation could read: "Performed by ———, dictated to ———."

Q. Must the physician perform other elements of the history also?

No. Ancillary staff may perform the ROS and PFSH. CMS officials reference E/M guidelines, which state, "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others."

Q. What about eye codes (920xx); do they require documentation of the HPI?

Not as discussed above. CPT does not specifically refer to HPI for eye codes. Instead, the definition only requires "history" and "general medical observation." No further details, explanation or illustrations exist to elucidate these requirements. OM