How to Avoid Downcoding with CC and HPI Coding Tips

How to Avoid Downcoding with CC and HPI Coding Tips

Many practitioners lose revenue because they are unsure how to code for an E/M visit and when uncertain of what code to use, you avoid risk by practicing downcoding. Here are some helpful tips to learn how to document your own HPI and avoid unnecessary downcoding.

The Chief Complaint (CC) and the HPI (History of Present Illness) can have a HUGE impact on the E/M level selection for a new patient. For example, the highest level for a new patient with a brief HPI is a 99202.

There are two types of HPI documentation: brief and extended. An extended HPI requires at least 4 distinct HPI elements that must relate to the Chief Complaint.

Every chart must have a clear Chief Complaint. It is very difficult to assign HPI elements when the Chief Complaint is “follow-up,” “testing,”or “refills”. It is important to state the condition or symptoms the patient is being seen for.

There are 8 different HPI elements:

  • Location – where on the body
  • Quality – description of the symptom (sharp/dull/throbbing, etc)
  • Severity – mild/moderate/severe, 1-10 on pain scale
  • Duration – when did the symptoms first start?
  • Timing- how often do symptoms occur? constant/intermittent/first thing in the morning
  • Context – what’s the story? fell off bike, lots of family stress, etc.
  • Modifying factors – does anything make it better or worse?
  • Associated signs and symptoms – dizziness with headache, vomiting after head injury, etc.

The provider MUST document their own HPI. This section cannot be completed by a nurse or tech, unlike the ROS or Past/Family/Social Histories.

A good rule is to always document at least 4 HPI elements on every chart. This may not automatically increase the E/M level, but it should help to ensure that a chart is not downcoded.

Let me know if you have any questions and need more helpful coding tips.

Kelli Rain, CPC, CPMA
Director of Coding