HPI: Context and modifying factors

Q: I have been asked to review some of our physician notes, and I was hoping that you could clarify for me the different elements of the history of present illness (HPI).

A: An essential part of evaluation and management (E/M) documentation is history of present illness (HPI). Two of the eight HPI elements are context and modifying factors.

The other elements of the HPI are:

• • Location

• • Duration

• • Quality

• • Severity

• • Signs and symptoms

• • Timing

In a previous Coding Insights, we discussed the HPI element of “severity,” so we will continue our discussion now to “context” and “modifying factors.” Keep in mind that all of the HPI elements might not be in the history portion of the note. Information may be gleaned from anywhere in the chart, so it is important for a coder to read through the entire note and for the physician/provider to remember to document the HPI details.

Context and modifying factors are two separate elements of the HPI.
Context is what was happening when the issue was first noticed or how the problem has manifested since onset. It is a description that paints a bigger picture of what has been or is going on with that problem. It also can be a description of the course of treatment that the patient has taken prior to coming into the office.

Example 1

“Stephanie was playing soccer when she landed on her right foot and she heard a pop.” 

This indicates that “playing soccer” was the context. If the physician further indicated that “after she went to the bench she started to rub it and it felt better,” this would be a modifying factor.

Example 2

“Upon review of Frank’s EKG strip, his PCP noticed irregularities for which he sent Frank to me.” 

This shows the course of treatment that the patient has taken prior to seeing the specialist. Seeing the irregularities on an EKG strip might also indicate that the patient is not exhibiting any symptoms. The physician may go into more depth at that point to see why the irregularities were found only on the EKG strip. The patient may turn out to be asymptomatic despite these irregularities.

Context may not always be when the problem started, but instead a subjective account of when it was detected by the patient or another person associated with the patient.

Additional examples of modifying factors are:

  “I took Tylenol, but it didn’t help.”  

  “When I sat down, it went away.”  

  “Every time I swing a golf club, I feel it.”  

Even if the patient did nothing to make a complaint better or worse, documentation to that effect still relates to the modifying factors element. In other words, credit can be given even for a negative response because the physician or provider asked the question.

The physician or provider should document everything he or she learns from discussion with the patient. This information supports medical necessity and justifies the code being billed.