Evaluation & Management Coding
Review of HPI Elements
Be prepared to discuss examples of History of Present Illness (HPI) and to answer questions but avoid
excessive instruction – much of it is like teaching an expert pianist basic scales.
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Always Required Duration: A measurement of time regarding when the complaint first occurred. For
example, began “in childhood,” “since 1995,” first noticed “two weeks” ago, “symptoms x 3d,” etc.
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Location: For example “chest” pain, sore “knee,” etc. Conversely, examples such as “COPD,”
“Diabetes,” and “Hypertension” are not locations - these are “chronic conditions.”
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Quality: Any characteristic about the problem and/or expresses an attribute. For example: how it looks
or feels; for example. “green” phlegm, “popping” knee, “dull” ache, “sharp” pain, “metallic” taste, etc.
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Severity: A statement of degree or measurement regarding how bad it is… that it is improved, it is
extreme pain, “Blood Sugar is 200,” feeling “better,” pain is bad enough “that the pt can’t sleep” etc.
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Timing: A measurement of when or at what frequency; i.e. “intermittent,” “constant,” in the “morning,”
lasted “5 minutes,” “occasional,” “on and off,” etc.
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Context: What the patient was doing, the environmental factors/circumstances surrounding the
complaint, for example, “while sleeping,” “MVA,” “slipped and fell,” after “eating peanuts,” “while
dusting,” “when arguing with his wife,” etc.
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Modifying factors: Anything that makes the problem better or worse, a factor that changes, improves,
or alters the problem. For example, improved “with Tylenol,” worse “when standing,” better “when
resting,” “calms down when mother feeds her.”
• Subjectivity Alert: Medication may be a modifying factor when it changes, improves, or alters
the problem. Otherwise, it is most often credited to PAST Hx. Some auditors will credit
medications that were used in an unsuccessful attempt to modify the condition as a “modifying
factor.”
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Associated signs and symptoms: Any associated or secondary complaints.
• PFSH definition of complete: At least one specific item from two of the three history areas must
be documented for a complete PFSH for the following categories of E/M services: office or other
outpatients services, established patient; emergency department; subsequent nursing facility
care; domiciliary care; established patient; and home care, established patient.
Physicians’ Ally, Inc. – E&M Coding – Review of HPI Elements
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