Get 1 Step Closer to 99285 Perfection With This HPI Primer

emergency medicine coding

Emergency medicine code 99285 seems to be popping up a lot lately because of potential overuse. To help give you your best chance at coding correctly, it helps to take a close look at each element involved. Today, let’s look at the history of present illness (HPI) requirement. The good news is that most of this information applies beyond emergency coding, so it’s a good refresher for all coders who report E/M services.

See Where History Fits in the Descriptor

Here’s the definition for 99285 with the acuity caveat and history portion in bold:

Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

As you can see, the history level required is comprehensive “within the constraints” imposed by the specific case. That language about constraints is sometimes called the acuity caveat. It acknowledges that getting details in an emergency setting isn’t always possible.

Tip: The 1995 and 1997 CMS E/M Documentation Guidelines state, “If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.” (The 1997 version uses the phrase “that precludes” instead of “which precludes.”) Follow this same thinking for the acuity caveat. If you want to apply the caveat to your coding (whether history, exam, or MDM), the documentation must spell out why the specifics of the case prevented the provider from meeting the components listed in the code descriptor.

Dig Into HPI Requirements

The AMA CPT® manual and CMS 1995 and 1997 Documentation Guidelines (DGs) all say a comprehensive history requires an extended HPI, chief complaint, review of systems (ROS) directly related to the problem(s) identified in the HPI plus a review of all additional body systems, and complete past, family, and social history (PFSH).

Today we’re focusing on HPI. Let’s compare and contrast the AMA and CMS definitions:

  • AMA: The first part of the AMA HPI definition is this: “A chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present.
  • DGs: The 1995 and 1997 DGs’ definition of HPI is similar to the AMA’s, but CMS pops in the phrase “or from the previous encounter.” So the wording in the DGs is this: “The HPI is 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.”

You’ll also find a difference in the elements included in HPI:

  • AMA: “This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem(s).”
  • CMS: According to 1995 and 1997 DGs, the HPI requirements are similar to CPT®, but add duration as an element (bold added):
    • Location
    • Quality
    • Severity
    • Duration
    • Timing
    • Context
    • Modifying factors
    • Associated signs and symptoms.

To count an extended HPI for Medicare reporting, there are some important differences between the 1995 and 1997 DGs. Watch for the addition in the 1997 DGs of the phrase “or the status of at least three chronic or inactive conditions.”

  • 1995: “An extended HPI consists of four or more elements of the HPI.”
    • DG: “The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.”
  • 1997: “An extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions.”
    • DG: “The medical record should describe at least four elements of the present illness (HPI), or the status of at least three chronic or inactive conditions.”

Final tip: Medicare has stated, “you may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 documentation guidelines to document an evaluation and management service.”

What About You?

Do you enjoy the piece-by-piece detective work of E/M coding? How do you approach it?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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