Coding Guidelines, E/M Coding

Quick Guide: Elements of HPI For E/M Coding

Okay, I’m the first to admit that I don’t like coding E/M. When I was first starting out and looking for coding jobs, I would do my best to avoid applying for anything that had any E/M mentioned in the job description. I ultimately lucked out, and got into radiology coding, which I love. Then later when I moved on…guess what my first assignment was–doing an E/M audit! I was lucky (again) that I had wonderful coworkers to help me along the way. But I do distinctively remember crying over it one day while working on it. It just wasn’t my thing. But over time, that has changed (a little bit) and now I  can do an E/M audit with less problems (and less crying). But it still is confusing and every time I work on anything E/M, I have to review everything to refresh my memory.

One part that I think can be a little confusing is going over the HPI and counting up the elements. In theory, you would think this would be the easy part. Maybe it is for some people, but not for me. So I review this and it helps, so I thought I’d share it here. This comes directly from the CMS website:

History of Present Illness (HPI) HPI is a chronological description of the development of the patients’ present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

 

  • Location (example: left leg)

 

  • Quality (example: aching, burning, radiating pain)

 

  • Severity (example: 10 on a scale of 1 to 10)

 

  • Duration (example: started 3 days ago)

 

  • Timing (example: constant or comes and goes)

 

  • Context (example: lifted large object at work)

 

  • Modifying factors (example: better when heat is applied)

 

  • Associated signs and symptoms (example: numbness in toes)

 

SOURCE: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf 

So, that’s it! Does this list at least help a little bit? I could attempt to go on and on about E/M and try to explain it in more detail, but I don’t want to confuse anyone even more. I feel like E/M is something that can only be learned by coding practice cases or just learned over time. I will share the audit sheet I use though. It is from Novitas and you can find it here. Please note though–this is the 1995 guidelines.

If you’re looking for the 1997 guidelines/specialty exam score sheets, go here.

These are by no means the only score sheets available. This is just what I personally use, so I thought I would share it on the blog.

 

Thanks for reading,

Lindsay

 

Midnight Medical Coding Products You Might Be Interested In:

 

Tabs for the ICD-10-CM Book: Get 60 printed, multi-colored, double-sided tabs. These can be used on any 2019 or 2018 ICD-10-CM book from any publisher.

 

 

 

 

 

 

 

 

Learn The 50 Most Common X-Ray CPT Codes-

Self-paced online course. Getting awesome reviews from fellow coders.

 

 

 

 

15 Question Practice Coding Test

Practice coding the ICD-10-CM and CPT codes of HIPAA compliant X-ray reports. Answers and rationales provided.

 

 

 

 

Tabs for the ICD-10-CM Book: Get 60 printed, multi-colored, double-sided tabs. These can be used on any 2019 or 2018 ICD-10-CM book from any publisher.

 

Like this post? Subscribe to our blog and get posts sent to your email! We do not spam or send anything annoying. We send 1 blog post a week tops. Sometimes we also send coupons/deals on our products.