About half of all instances of cardiologists over coding CPT code 99214 are caused, in part, by deficient History of Present Illness (HPI) documentation. If you are limited to mastering just one component of the documentation guidelines, let it be the HPI.
Reading this brief post may substantially reduce your probability of having a note found to be deficient in the event of an audit. But please keep in mind that the HPI is only one of several documentation components that need to be in a note to support any given level of service.
There are eight recognized HPI elements. Providers typically need to document at least four of these to support a 99214. Exceptions to this rule include situations in which the note establishes that history cannot be obtained due to the patient’s condition, time-based billing of the visit, notes that contain the status of at least 3 chronic/inactive conditions documented in the subjective potion of the note, and notes that have sufficient exam and complexity components documented to meet code 99214’s documentation standard without relying on any history components. These exceptions apply in some cases but the large majority of notes benefit from a hearty HPI.
Cardiologists can only secure credit for each of the 8 elements of HPI 1 time. For example,, the statements “patient reports shortness of breath” and “the patient reports shortness of breath, chest pain, nausea, vomiting, & vision disturbances” both generate credit for just one HPI element - Associated Signs and Symptoms. In order to support the higher levels of service, the note must hit on four different HPI variables.
The official documentation guidelines define the History of Present Illness (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. It includes the following elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.”
Common examples have been listed below to illustrate each element.
location: the area of the patient’s body affected
Atrial Fibrillation, coronary artery disease
quality: distinctive characteristics of the problem
Sharp chest pain, paroxysmal atrial fibrillation
severity: intensity of the symptoms or problem
Pain is a 7 on a 1 to 10 scale
duration: how long the problem has been present
Diagnosed with CHF 2 years ago, pain lasts for 10 minutes
timing: a description of when the symptoms exist
Symptoms are worse in the evening
context: Circumstances, cause, precursor, outside factors
Symptoms are attributed to sleep apnea
modifying factors: anything that modifies the condition
Chest pain with exertion
associated signs and symptoms: conditions related to the problem
Patient also has shortness of breath
Several years ago I received clarification from the Centers for Medicare and Medicaid Services that HPI elements may be documented as being either positive or negative. This is an extremely beneficial clarification. However, many cardiologists do not routinely document negative responses to their HPI questions. The statement “denies symptoms” generates the same amount of credit as the previously presented statements: “patient reports shortness of breath” and “the patient reports shortness of breath, chest pain, nausea, vomiting, & vision disturbances.” All three of these statements generate credit for just one HPI element - Associated Signs and Symptoms.
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