History of present illness: Duration vs timing

Q: What is the difference between duration and timing as part of the history of present illness (HPI)?

A: Elements of HPI include severity, context and modifying factors, but it also includes the elements of duration and timing.

To the nonmedical eye, duration and timing may appear to be the same thing. But, according to documentation guidelines, these two elements of the HPI can be very different.

DURATION 

(How long?)
Length of time it has been present

TIMING 

(Is there a pattern?)
Continuous or repetitive

Establishing the onset for each symptom or problem and a rough chronology of the development of the problem are also important. To do this for duration, it’s important that the provider ask: How long have you had these symptoms? When was the test run that confirms that diagnosis?

To do this for timing, the provider may ask: Is it primarily nocturnal, diurnal or continuous? Or has there been a repetitive pattern for the symptom? Also, there could be an event that causes or triggers the problem (e.g., burning in the chest area happens after eating spicy food, knee pain hurts the worst in the morning, the fever has been off and on throughout the day). Of course, each of these questions should be driven by the medical need to know.  If it’s not pertinent to understand the patient’s condition, these areas (as with all) HPI elements should not be counted towards the level of HPI, or in turn, the Evaluation and Management code level.

The documentation and the circumstances can be obvious or obscure. Here are some real-world examples on the differences between the two to ensure correct coding and documentation. 

Obvious example

An example of where both elements would easily satisfy HPI requirements would be, “Mrs. Blummer has been experiencing periodic episodes of cramping. They last for about 3 to 5 minutes throughout the day. This has been going on for the past few weeks.” The duration in this example would be “past few weeks.” The timing would be “3 to 5 minutes.” The duration describes how long the symptoms have been present, while the timing specifies how long the symptom lasts when it occurs.

Obscure example

Less obvious would be a note that reads, “For the last two weeks, Mr. Granger has been experiencing intermittent arm pain.” “Two weeks” would be the duration and “intermittent” would be counted as timing in this case. Timing could also be something as general as “the patient has abdominal pain after eating tacos.”

Don’t forget that these elements can be documented anywhere in the note as long as the provider documents the information.  In order to count HPI elements toward the level of code billed, they cannot be documented by anyone other than the provider.