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HPI: a new documentation option
Plus, documenting a complete review of systems

Keywords: CMS announces a new documentation option for the history of present illness


by Kristy Welker, CPC



Published in the January 2014 issue of Today's Hospitalist

WITH ALL THE DISCUSSION last fall of Medicare's new two-midnight rule for inpatient admissions, we failed to note another development: a new option for documenting the history of present illness. Here are some questions I've received from readers about evaluation & management (E/M) guidelines, including that new option, and my answers.


Keep up with the latest coding changes: May 2014 - Coding News & Strategies


Documenting HPI
I was told that I can use the status of three chronic problems when documenting my history, as per the 1995 E/M
After performing a complete review of systems, document all positive and pertinent negative systems.

guidelines? Is this true?

The answer is "yes" for evaluation and management services provided to Medicare patients performed on or after Sept. 10, 2013. As of that date, you now have another option for meeting an extended level of history of present illness (HPI).

The Centers for Medicare and Medicaid Services (CMS) now allows "the status of three or more chronic or inactive conditions" to qualify as an extended HPI. Previously, you could not use the status of three or more chronic conditions unless you were using the 1997 documentation guidelines. Here's what the CMS posted on its "frequently asked questions" Web section pertaining to the 1995 and 1997 E/M documentation guidelines:

"Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code?

For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service."

As a result of this change, you now have two documentation options to meet an extended HPI: You may document the status of at least three chronic or inactive conditions OR document at least four elements of the HPI.

If you choose to take the old route and document the HPI elements, here are the different components you can consider:

  • location: physical location; n quality: how is the symptom further described, such as "sharp," "dull" or "radiating" pain;
  • severity: refer to the pain scale or use descriptors like "worse," "better" or "severe";
  • associated signs and symptoms: such as rash, cough, fever;
  • timing: the course of symptoms such as "comes and goes," "intermittent," "off and on";
  • context: the cause or activity onset of the problem such as "struck by a car" or "following a bad cold";
  • modifying factors: what helps, how are symptoms relieved or worsened, how are symptoms affected and by what, such as "took aspirin w/no relief," "worsens with walking"; and
  • duration: when did the problem begin, length of time since, such as "on Friday night," "past 2 days," "2:00 today."

    Remember, whichever route you choose to meet the HPI requirement, documenting an extended HPI is critical to support both a higher level of initial hospital visit (99222, 99223) and of observation services (99219, 99220, 99235, 99236).

    Consultation codes
    What defines an established vs. a new patient for Medicare consult code billing?

    Although the AMA still recognizes consultation codes as valid CPT codes, Medicare eliminated the use of both outpatient consult codes (99241-99245) and inpatient consult codes (99251-99255) in January 2010.

    But to apply your question to those payers that still accept consult codes, these codes are not based on new or established patient guidelines. Consultations should be used for patients receiving a service provided by a physician or other appropriate source whose opinion or advice regarding a specific problem or treatment is being requested by another physician or provider.

    CPT defines a "new patient" as one who has not received any professional service from a physician or from another physician in the same specialty and same group practice within the previous three years. But being a new or established patient would not apply to any code used for hospital-based inpatients. (It would, however, apply to some codes for domiciliary, rest home and custodial care.)

    Complete ROS
    Does "All systems reviewed and all are negative" or "10 systems reviewed and all are negative" qualify as a complete review of systems (ROS)?

    Medicare's evaluation and management services guide gives this guidance: "A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented."

    Documenting the ROS as you stated in your question—"10 systems reviewed and all are negative"— may support a complete ROS. But it would likely leave the medical necessity of the visit in question. If all systems are negative, why are you seeing this patient? What is the presenting problem being addressed?

    Unless the patient is being seen for a preventive medicine visit, which would be highly unlikely in the hospital, you should have some complaint to record in the ROS. Here's my suggestion: After performing a complete review of systems, document all positive and pertinent negative systems. You can then use this statement: "All other systems negative or WNL" (within normal limits).

    Kristy Welker is an independent medical coding consultant based in San Diego. You may e-mail your documentation and coding questions to her at kristywelker@hotmail.com. We'll try to answer your questions in a future issue.
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