CODING & REIMBURSEMENT

Master history of present illness documentation

By Suzanne Corcoran

It’s just as important for you to document the history of present illness (HPI) as it is to document the chief complaint. Here are our instructions for how to do that correctly and support reimbursement.

Q How does the HPI impact the level of service?

A In addition to the chief complaint (CC), which is the reason for the visit, the history of present illness (HPI) is one component of the medical history. The others are the review of systems (ROS) and the past personal, family and social history (PFSH). Each of these components has an equal weight.

To reach the higher level evaluation and management (E/M) codes, an extended HPI is required. This means you must document four components. The elements of the HPI are: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. A lesser number of elements (one to three) may be reasonable, but will support a lower level of E/M code.

Q Who may perform the components of the history?

A Ancillary personnel, including ophthalmic technicians, may take the CC, the ROS and the PFSH. However, under Medicare guidelines, the physician must personally perform HPI to count toward an E/M level of service. One Medicare Part B contractor, Noridian, has published that,“E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner…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…may be used as preliminary information, but needs to be confirmed and completed by the physician.” We have seen similar instructions from other payers as well.

Q Is use of a scribe permitted?

A Yes. A scribe may record the HPI dictated by the physician. We strongly recommend that the physician document personally performing the HPI when using a scribe, either in paper or EHR. In a paper chart, an attestation such as “Performed by ____, dictated to ___” serves nicely. In an EHR, some mechanism for making a similar notation is required. Check with your EHR vendor to see how this should best be done. Corcoran does not believe that the physician’s electronic signature at the end of the record is sufficient in the event of a payer audit.

Q Do the eye codes (920xx) require documentation of the HPI?

A No; CPT does not specifically refer to HPI for eye codes. Instead, the definition only requires “history” and “general medical observation.” This makes the eye codes easier to document and is one reason why eye-care professionals favor eye codes. Unfortunately, not every exam can be coded with the 920xx codes, so understanding and complying with E/M requirements is necessary.