While supplies last! Free 2022 Coding Essentials for Infusion & Injection Therapy Services book with every RACmonitor webcast order. No code required. Order now >

The 20-year-old evaluation and management (E&M) documentation guidelines are full of different components and elements, all of which must be reviewed in order to ensure that services billed were appropriately documented.

If you look at the full list of components (history, exam, and medical decision-making) and their subcomponents, there are 66 different scoring elements. Then you have to consider all the possible thousands of combinations possible when “adding” those elements. All 66 elements have ambiguities and complex guidelines that are not always clear in any given scenario, so you should discuss each element with your auditors and agree on setting specific auditing policies for them. In an earlier article, I discussed several of these components, including the chief complaint and the guidelines, and suggested policies to accompany them.

In this article, I will discuss the history component and the individual elements of the history of present illness (HPI).

The HPI of the encounter should include symptoms the patient is experiencing due to his or her chief complaint. These symptoms include eight distinct possible elements. 

  1. Location
  2. Duration
  3. Quality
  4. Severity
  5. Timing
  6. Modifying factors
  7. Associated signs and symptoms
  8. Context

Keep in mind that the information we give “credit” for in these areas should pertain to the chief complaint and not the patient’s signs and symptoms. Most auditors give credit for information about signs and symptoms regardless of their relevance to the stated chief complaint. Unfortunately, we often do not get enough information in the record to make this distinction, which can lead to different interpretations by different coders and auditors. To ensure consistency, specific auditing policies should be drafted to address each of these eight elements.

Below are some specific examples. 


Concern No. 1: Some believe that having a one-word location such as “knee” is not specific enough, and that credit should only be given for a more specific location, e.g., “left knee.”

Recommendation No. 1: Location is location, and the rules do not require specific locations such as laterality on top of a body part or anatomical area. Thus any noted location would be appropriate.

Concern No. 2: Using a documented symptom or a diagnosis and giving location could be problematic (i.e., listing the endocrine system as location when diabetes is mentioned).

Recommendation No. 2: Unfortunately, this is not specific enough and therefore credit should not be given for location based on the mere mention of a symptom or diagnosis. Many of the Medicare Administrative Contractors (MACs) have posted guidance about their E&M requirements that support this standard. 


Concern: Only the pain scale may be used to document severity.

Recommendation: There is no guidance indicating that only the pain scale may be used to support severity. Therefore, any word or phrase that conveys the severity of the condition should be credited. Common examples expressing severity that would meet this standard include “mild,” “moderate,” and “severe.”


Concern: Giving credit for duration based on any reported amount of time documented in the HPI is another issue to consider. For example, this would include crediting duration for the phrase “patient had prostate biopsy six months ago.”

Recommendation: Duration should define how long the patient has had the problem or symptom relating to his or her chief complaint, not how long it has been since a procedure, admission, or discharge. 

Modifying Factor

Concern: The modifying factor must include not only what steps a patient has taken to try and alleviate the problem, but also the effects of these steps on the patient.

Recommendation: While including information about how the patient was affected may help illustrate medical complexity, there is no requirement in documentation guidelines that requires recording the effects of modifying factors.

The other elements of HPI are not as controversial as the ones we covered above, but I have found that auditors often develop their own specific definitions of elements and at times fail to see other contributing points that may very well support them. The remaining HPI elements and points to consider for each should be reviewed to ensure that appropriate credit is given to the provider being audited. 

Quality: When I am teaching providers about documentation guidelines, I try to encourage them to use the terms “stable,” “chronic,” or “worsening” to convey quality; therefore, when I audit for quality, I tend to look for these words. However, “quality” can be any term that is used to describe the problem. Pain is a good example to illustrate this further. Any term that is used to describe pain may support the quality element. For example, “the pain is sharp,” or “the pain is throbbing/stabbing,” or “the pain is chronic,” or even “the pain is unchanged at this time” is a valid descriptor. Each of these phrases illustrates the scope of the problem.

Timing: Timing demonstrates when the patient is affected most by his or her chief complaint. One way of giving credit for timing that is not often used is looking for events that demonstrate timing. Most notably, we give credit for such sample phrases as: “patient has pain in the morning,” “patient states pain is constant,” or even “patient states the problem comes and goes.” Also, you should look for “hidden” timing that may appear in the form of statements such as “her sugars vary most at breakfast” or “her back hurts when she wakes up in the morning.” Timing always should indicate to the provider how often the patient is having the problem or whether events that occur at specific times affect the problem.

Context: Context is most commonly defined as “what was the patient doing when he or she began having the problem.” When teaching, I usually use a silly example such as “her pain began when she fell off the ladder, which was propped up against a tree.”Such statements may seem overly obvious, but they demonstrate the point. Remember that factors present before or after the problem can support context as well. HPI should include symptoms the patient is experiencing due to his or her chief complaint. Therefore, we commonly note that negative findings in the HPI are truly ROS and not HPI, but there is an exception to this: no known injury or accident. If the patient had an injury or accident, then the severity of the encounter may shift in complexity.

Associated Signs or Symptoms: This element is probably one of the most clear-cut and least controversial, but there is still one tip to keep in mind. If you use a sign or symptom in the HPI, then you may not use it again to count toward your ROS elements. 

It is not unusual to feel that HPI can be truly confusing when you try to assign a level of service. When I am teaching E&M auditing to medical auditors, I usually spend several hours just on history. Having medical auditing policies specific to your organization that spell out what your expectations are for each element will yield more consistent findings from those auditing and those being audited.

About the Author

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. 

Contact the Author


Comment on this Article



You May Also Like

Leave a Reply

Your Name(Required)
Your Email(Required)