Who can document the HPI?
January 30th, 2010 - Todd ThomasCategories: Coding Evaluation & Management (E/M)
A common question amongst coders that routinely deal with E&M services.
The E&M Guidelines specify which elements can be recorded by someone other than the physician. "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others." Standard legal and rule making logic "when something is omitted from a list of what is approved, the omission is forbidden and can't be included".
If you review the April 1996 CPT® Assistant describing the elements of an HPI. You will see the definitions of the HPI elements always refer to the physician or clinician
Most experts agree that the absence of AMA or CMS coming out and saying that someone other than the physician can do the HPI means that it must be performed by the physician.
There is also the following quote from Dr Bart McCann to show the physicians that they are expected to perform the HPI.
"The physician must write an HPI Statement. It is understood the residents and other ancillary staff may collect some of this information as well but this does not absolve the physician of the duty to verify the information and summarize the HPI statement his / herself. The ROS past family and social history maybe obtained and documented by someone other than the physician. However, the physician must review and comment on the information, whereas in the HPI the entire thing must be done by the physician."
Quote from Bart McCann, MD
Executive Medical Director HCFA
Printed in Physician Practice Coder,
December 1997.
There is also this FAQ that was published in the November 2003 Communiqué. It also available at http://www.wpsic.com/medicare/provider/doc_faq.shtml
Frequently Asked Questions (FAQs)
Who can perform the History of Present Illness (HPI) portion of the patient's history? (04/01/04)
The history portion refers to the subjective information obtained by the provider or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the history of present illness (HPI) portion of the patient's history. Only the provider can perform the HPI.
From FAQs at the WPS site
Q. If the nurse takes the History of Present Illness (HPI), can the physician then state "HPI as above by the nurse" or just "HPI as above" in the documentation?
A. No, the physician needs to fully document the HPI.
Q. Who can perform the History of Present Illness (HPI) portion of the patient's history?
A. The history portion refers to the subjective information obtained by the provider or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the history of present illness (HPI) portion of the patient's history. Only the provider can perform the HPI.
The issue has been clarified several times with Cathleen Scally at CMS and she has verified that HPI must be done by the billing provider. There was a past discussion about a possible misquote of Dr. McCann in a 1998 article that indicated that he said it was acceptable for someone else to document the HPI as long as the physician reviews/adds to it.
The quote in question was forwarded to Ms Scally who then wrote to Dr. McCann to determine whether or not he had been misquoted in the publication, pointing out that CMS has never permitted anyone but the physician/NPP who is performing the E/M to do the HPI. She also noted that in certain circumstances like an ER where a triage nurse takes the initial chief complaint and perhaps even an HPI it is required that the physician/NPP of record must actually review the chief complaint and HPI with the patient and write it him/herself and not just sign what an ancillary employee may have recorded.
Dr. McCann's response to Ms. Scally was clear and unequivocal:
"Kit, I totally concur with your interpretation. What kind of doctor doesn’t take his/her own history?"
That should make it perfectly clear. All of the HPI elements must be taken from the Doctor's notes.
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)
COVID Vaccine Coding Changes as of November 1, 2023October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M ServicesOctober 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?October 10th, 2023 - Aimee Wilcox
When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.
Accurately Reporting Signs and Symptoms with ICD-10-CM CodesOctober 5th, 2023 - Aimee Wilcox
Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.
The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin ResistanceSeptember 19th, 2023 - Aimee Wilcox
Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.
Documenting and Reporting Postoperative VisitsSeptember 12th, 2023 - Aimee Wilcox
Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period?
Understanding Gastroesophageal Reflux Disease and ICD-10-CM CodingAugust 22nd, 2023 - Aimee Wilcox
Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.
