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."
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.
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.
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.”
So what are those requirements?
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.
Implants could be considered ...
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...