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Number of HPI Elements?

Deanna Posted Mon 02nd of April, 2018 19:02:55 PM
We are going back and forth of the number of HPI elements that can be pulled from an HPI similar to this one. "This is a 42 year old male who I saw week before last as an outpatient. The patient requested an OP detox. I gave her a 48-hour detox using Suboxone and some Tranxene. He has failed OP detox. He is abusing Heroin, tranquilizers, Amphetamine, Crystal Meth and some IV drugs. The patient is admitted for detox and to get into treatment." Could you please tell me how many HPI elements you get from an HPI such as this, and which elements it falls into? This is a normal service by this provider and want to make sure we are using everything that we can to bill appropriate E/M levels for his services. Thanks in advance!
SuperCoder Answered Tue 03rd of April, 2018 09:12:29 AM


To determine the HPI level, you'll need to know the elements of HPI. "As a guide to the provider when trying to delineate the nature of the illness, CPT has defined specific elements to consider when interrogating the patient," says Herman. These elements are:

  • location,
  • quality,
  • severity,
  • timing,
  • context,
  • modifying factors,
  • associated signs and symptoms (Note: Medicare adds an 8th potential HPI element of duration)

In order to arrive at the proper HPI level, you'll need to know how many of these elements your physician addressed during the patient interview. By definition, a brief HPI consists of one to three elements and an extended HPI has four elements or more.

As per above mentioned documentation the HPI count would be 3 only. Detox will be consider as context, 48 hours detox as timing, and modifying factors would be heroin, tranquilizers, Amphetamine.


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