Who can document the HPI?

January 30th, 2010 - Todd Thomas
Categories:   Coding   Evaluation & Management (E/M)  
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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.
http://www.wpsic.com/medicare/providerfaq/eandm_faq.shtml#documentation_2
 
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.
http://www.wpsic.com/medicare/providerfaq/eandm_faq.shtml#documentation_6
 
 
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.

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