Evaluation and management codes
Understanding the history of present illness
History of Present Illness (HPI): In a nutshell
- The History of Present Illness (HPI) describes the development of your patient’s condition in their own words.
- There are eight possible elements in the HPI.
- When coding for HPI, it usually doesn’t matter how many of each elements you review. All that matters is the number of elements you document.
- A brief HPI documents one to three elements. An extended HPI documents four or more elements.
E/M Coding Tool
Select the button below to access the Academy's E/M coding tool for office encounters.
Access ToolYour patient has come in with six different complaints, plus he’s crying. You have filled out the location and symptoms for each problem. But the auditor comes back and says that you have only documented two HPI elements.
Huh?
The history of present illness (HPI) describes the development of your patient’s present condition in their own words. It is an important part of the history component when coding for evaluation and management (E/M) services.
Be warned that it is not as straightforward as it seems. According to CMS, there are eight distinct HPI elements.
It doesn’t matter how many items are within each element. The only thing that matters is the number of elements you document.
For example, if you document that the patient has a rash on his arm, torso, and leg, this only counts as one element. Even though you listed the location of three distinct rashes, you still only used one element (location).
However, if you document that he has a rash on his arm, torso, and leg, and that these developed a week ago, you have now covered two elements (location and duration).
No matter where you practice, it’s always a good idea to check with your patient’s insurance carrier. Some carriers may allow certain elements to be counted more than once if they’re for distinct problems.
Code like a pro
Find everything your practice needs to code with confidence. Purchase complete code sets and webinar training for the team in the AAD Store.
Categorizing the HPI: Brief vs. extended
There are two ways of categorizing an HPI.
A brief (problem-focused) contains one to three HPI elements.
The extended (comprehensive) is a bit more complex, with four or more HPIs.
Now, a quick question. Is your documentation based on 1995 or 1997 guidelines?
If you are coding the visit using 1995 documentation guidelines, there’s only one way that an HPI can be considered as extended. You have to document four or more elements of the HPI or associated comorbidities.
If you use the 1997 documentation guidelines, there are two ways an HPI can be categorized as extended:
You document four or more elements of the HPI, or
You document the status of at least three chronic or inactive conditions
You can test your knowledge of E/M coding by taking a short Academy quiz, or see other coding quizzes.
Related Academy resources
Our coding staff experts will respond to your query within 48 business hours.
Download these coding tip sheets for practical guidance on common coding.
Stay current on coding and reimbursement topics.
