Dear Coding Support: Evaluation and Management Coding

Coding and BillingNo Comments

Dear Coding Support,

Help! I am having a difficult time with evaluation and management coding. Deciphering between quality and severity HPI elements is a challenge. Every time I choose severity based on what the medical record is describing the answer key comes back and tells me I should have selected quality instead. What am I missing?


Dear Confused,

Don’t fret, E/M is challenging to learn; it is sometimes difficult to break up each piece of information into a history of present illness (HPI) element. It takes time to figure out how to correctly “pigeon hole” information into the categories. By definition, a quality element will describe how the chief complaint looks or feels. Watch for descriptive information such as sharp, dull, red, as quality elements. Severity elements are defined as a degree or a measurement of the severity. Examples of severity include a third degree burn, or a two centimeter laceration. Remember that HPI elements are all subjective; this is information coming from the patient as they are describing the chief complaint.  Hopefully this will help you distinguish between the two elements.

Coding Support



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