# Documentation of Chief Complaint



## uksjmartin

Can ancillary staff document the chief complaint?


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## RebeccaWoodward*

No..Must be MD.

*Ancillary Staff and Patient Histories *

*Q What portion of a visit can ancillary staff perform and document? Can they perform and document the history of present illness (HPI) or chief complaint (CC) if I read their documentation and notate that I have done so and agree with it? *

A According to the 1995 and 1997 E&M documentation guidelines, the only portions of the history that may be recorded by the ancillary staff of a physician are the Review of Systems and Past/Family/Social History, and those portions must be reviewed by the physician. The physician must also write a statement supplementing or confirming the information recorded by the ancillary staff. 

*CMS recently clarified that only the physician or nonphysician practitioner who is conducting the E&M visit can perform the HPI and CC, stating that this is physician-level work and shall not be relegated to ancillary staff*. 

The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded, or scribed, and write a notation that she reviewed it for accuracy and did perform it, adding to it if necessary and signing her name.


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## LLovett

Can you please post the link to CMS stating this?

Thanks

Laura, CPC


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## RebeccaWoodward*

Ohio Part B Carrier 
What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an Evaluation and Management encounter? Can ancillary staff act as a scribe for a provider?

*Ancillary staff may ONLY document: 

Review of Systems (ROS) 
Past, Family, and Social History (PFSH) 
Vital Signs *
These three areas MUST be reviewed by the physician or NPP who MUST write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can PERFORM the History of Present Illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances an Office or Emergency Room triage nurse may document pertinent information regarding the Chief Complaint/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

Scribe (E/M Services):

If ancillary staff is present while the physician is gathering further information related to the HPI or any of the three key components, he/she may document (scribe) what is dictated and performed by the physician or NPP. The physician needs to review the information as it is written, documented, recorded or scribed and write a notation that he/she reviewed it for accuracy, add to it if supplemental information is needed, and sign his/her name. The name of the scribe must be identified in the medical records.

Ancillary staff does not need to be employed by the physician (example: hospital employees).

Resources: 

CMS 1995 & 1997 E/M Guidelines - http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp 
Palmetto GBA E/M Help Center, located in "Articles": 
Ohio: http://www.PalmettoGBA.com/boh 
West Virginia: http://www.PalmettoGBA.com/bwv 
South Carolina: http://www.PalmettoGBA



http://www.palmettogba.com/palmetto...ncillary staff act as a scribe for a provider

http://www.wisconsinmedicalsociety.org/education/faq#q16


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## RebeccaWoodward*

Also......

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. 

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.


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## LLovett

I don't have a problem with the HPI being done by the provider. I do have a problem with the statements regarding CC. 

HPI and chief complaint are not the same thing. 

Is there something that specifically states the provider has to obtain the cc? The only thing I find on cc is that it is required at all levels of history and that it is usually in the patients own words.

Thanks,

Laura, CPC


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## RebeccaWoodward*

Laura,

Typically, I see "eye to eye" with you but not in this case.  CMS has made it clear, or so to me, that ancillary staff cannot document the CC.  There are many other articles and well known coding guru's that agree with this ideology.  I don't know about your carrier but my local carrier always emphasizes this requirement at our conferences.  

DG-*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.*

AAOS---  "The chief complaint (CC) and history of present illness (HPI), however, are different from the rest of the components in the patient history. Reporting and documenting the CC and HPI must be done by the physician or NPP reporting the service."

http://www.aaos.org/news/bulletin/oct07/managing8.asp

I'm not suggesting that ancillary staff can't write down the reason for the visit but it's very clear that the physician must acknowledge/add/sign...something in addition to this comment.  

"To agree or not to agree"...at least we can still have a healthy discussion whether *we* agree on the subject or not.


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## LLovett

Rebecca,

I don't mean to be argumenatative but this could have a huge impact on hundreds of providers at my facility alone, and until I have something in hand from CMS clearly stating they have to do it, I am not comfortable telling them that is the way it needs to be done.

Myself and other coders I work with are having a hard time seeing how this is required based on the guidelines, and my facility will accept nothing less than requirements that come directly from CMS or WPSmedicare. 

On another post regarding this topic, an article by Risë Marie Cleland was quoted as a source supporting this. I emailed her and she could not find supporting information from CMS, she sent me links to Noridan and Palmetto GBA. I just got off the phone with Noridian, they clearly state it came from CMS in their article but they can't direct me to their source. She is supposed to do more research and call me back. As soon as or if I ever get a call back I will post the response I get.

I am a total stickler for compliance and I will make sure all the providers I am responsible for do everything per the guidelines that apply to us. I just have to prove it applies to them in order to keep the peace.

Thanks for taking time to post your sources!

Laura, CPC


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## RebeccaWoodward*

No no...I didn't take your comments as argumentative.  Unfortunately, the coding/compliance world can be clear as mud...  Someone tossed this excerpt from Noridian into my lap....

Medicare Part B

Evaluation and Management Clarification  

The Centers for Medicare and Medicaid Services (CMS) has clarified that only the physician or non-physician practitioner (NPP) who is conducting the evaluation and management (E&M) visit can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff. 

Noridian Administrative Services (NAS) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when “physician” criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name.

Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be “I have reviewed the HPI and agree with above.”

Applies to the states of: AK, AZ, CO, HI, IA, MT, ND, NV, OR, SD, UT, WA & WY.

Effective Immediately 

This article was posted to the Updates section of the Noridian website on May 21, 2007.  

Posted: 5/21/2007 by NAS, LLC 

Is this what you were referring to?


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## LLovett

That is the one. As of yet, Noridian still hasn't called me back with the source document they are siting. I find it interesting that they don't link to it from the article. WPSmedicare is always really good to put a link to the CMS source document.

Laura, CPC


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## FTessaBartels

*Definition of chief complaint*

I find it interesting as well that the carriers get more and more specific about what they expect the physician to document ...

Especially when the definition of a chief complaint is the problem that brings the patient to the physician, "*usually stated in the patient's words*" (source: CPT 2009 professional edition, E/M services guidelines, page 1).

In other words, the patient is here because his leg hurts, not because he has a fractured tibia. 

Oh well ... 

We are covered by WPS Medicare and we DO ask the physicians to document chief complaint themselves. If they don't we have to take it from the first sentence of the HPI (so they don't get any HPI credit for that - no double dipping). A few audits with their E/M levels being lowered is usually pretty effective in getting them to document the CC themselves. 

F Tessa Bartels, CPC, CEMC


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## LLovett

*Noridian called me back*

Well, interesting info today. 

Ashley from Noridian called me back. The before mentioned article was written by a lady on their education staff. She based her article on the MLN articles about 95 and 97 guidelines, not on something stating chief complaint must be done by the provider.

Noridian told me even though it doesn't say anything about who can document the CC in the MLN documents, that is where this idea came from.

They gave me a phone number and name to a medical director that approves these articles. I tried to call him and the line is currently being checked for trouble. 

As I learn more I will post it. 

Laura, CPC


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## dmaec

seems a bit overkill at this point.  I mean really, since the provider does the HPI why wouldn't they ALSO be stating the CC?  Are they going to do a complete HPI without ever mentioning the CC? (the reason the patient is even there in the first place)... doesn't make sense to me.  The HPI and CC are "one in the same area" of the HISTORY component.  Along with the ROS and PFSH that make up the HISTORY Element, and with the other ELEMENTS of the service (EXAM/MDM) the level is finally determined.  

I don't get why it's such an issue - why there has to be something in stone. Do your providers want the ancillary staff to document the CC?  I mean, is it THAT much of a bother to them that they can't or won't state the CC in their dictation?  

what am i missing?

I feel it's pretty basic, straight forward and should go without saying that the CC is done right along with the HPI which is done by the provider.  I also agree with Tessa & Rebecca and their posts.  
More so, I still can't figure out this would (or should) be an issue.


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## LLovett

Apparently you have providers that document much better than a lot of mine do.

Good example, nurse documents "1 week recheck ears"

provider does the hpi "doing better, finished meds"

Based on needing a chief complaint to bill any E/M service, if the cc is invalidated b/c the nurse wrote it, I can't bill for this service at all.

I have over 500 providers that could be affected by any changes I advise, Yes I need something in writing from CMS or at this time WPS. 

I am sorry if this posts bothers anyone, I will keep any future information I obtain to myself. 

Wishing you all the best,

Laura, CPC


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## dmaec

I was simply stating my opinion Laura - the post's haven't upset me (I'm sorry if mine upset you).  Feel free to offer your info and opinion to all - that's what this is for, the "Forum thing" ... to help out others, to ask questions, to post responses, opinions, help, guidelines, etc....  

sorry my opinion and inability to understand why this should be such an issue at your facilty has upset you.  But don't take the fact that my post upset you out on all others.. I'm sure they're waiting for more info when you find it, and even I am anxious to see if you come up with anything written in stone. (or whether it even has to be!)

I would have to believe that of your 500 providers, the majority of them follow the documentation guidelines and document the CC right along the HPI and info from the ROS/PFSH(regardless of who obtains that), along with the EXAM and MDM.  I'm having real difficulty believing that a provider would see a patient, document the HPI, ROS, EXAM and MDM and fail to mention the CC. Even the stuff ancillary does is dictated in the note or should be, right?


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## kathymoon

I have to agree with Laura.   I have some providers who simply state 3 month recheck and states their chronic diagnoses.  I am trying to get better documentation but some of them are simply stuck in their ways.  I also would like some real documentation that states that the physician (or PA) must document the HPI and CC.  I know this doesn't exactly make sense to Donna but when docs try to simply cut time and try to pass off as much as they can to their MA.  Laura, if you come up with any documentation let me know.  You can send me a private message if you'd like.  Thanks.  kathy


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## LLovett

I am still waiting for a response from an emailed question, the ph# they gave me has now been disconnected. As of right now the only thing I can find from WPSMedicare supports that the only part of the history that has to be documented by the physician is the HPI. Which is how I have always understood it to be.

http://www.wpsmedicare.com/part_b/publications/em_history.shtml


Donna, I don't know where you are located but it is apparently not in southeastern Ohio or Mid Michigan, trust me the majority are not following guidelines. It is really scary what is going on and no wonder the OIG is cracking down. I personally have been charged level 5 consults by 3 different specialists (cardiology, gastro, and gen surgery) and the only people that ever saw me were residents, I didn't even get the pleasure of meeting the doctors that the services were billed under, much less actually receiving the service they billed for. Thankfully none of them were my providers but I have no doubt this is very common, in this area at least, because these providers were all from different offices. This was in Feb of this year. The same thing happened at a completely different facility in Jan of this year when my daughter was in the hospital. I know that is a bit off topic but I just wanted to illustrate the type of environment I came into back in September 2008, these type of things were seen as ok when I came in. Obviously they are not and I am doing my best to change that but when "everyone else does it that way" you have to support the things you want them to change.

Laura, CPC


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## LLovett

*Finally got a response from WPSMedicare*

"As you probably know, the Centers for Medicare & Medicaid Services (CMS) does not specify who may record the chief complaint (CC) component of an evaluation and management (E/M) service in either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services. Although CMS has clarified that only the physician or non-physician practitioner performing the E/M service may document the history of present illness (HPI) element of the exam, WPS Medicare does not interpret this to mean that the ancillary staff may not question the patient about their chief complaint. WPS Medicare will permit ancillary staff to record the CC; however, the physician/NPP must validate the CC in his or her documentation.

WPS Medicare recently published an article containing questions and answers pertaining to the history component of E/M services. Question one in the list of questions and answers specifically addresses ancillary staff recording the patient's chief complaint. You may wish to review this article on our Website at the following address: 
http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml "


This is the response I got back from WPS today. According to this as long as the physicians documentation supports the cc it is ok for ancillary staff to obtain it. 

Laura, CPC


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## amjordan

I have been following this post and I think it is a perfect example of the "mud" we deal with everyday.  Thank you all for the information you have provided from the different carriers, it provides a clear picture of how important it is to know what your specific carrier rules are.  

My group is now part of the J5 MAC that was awarded to WPS and we have been struggling trying to get answers to several questions related to E/M's for the past year.  We formed an E/M Workgroup of coding and compliance managers, consultants and instructors all of which are CPC's and several of them are members of the WPS POE-AG.  When WPS finally published their E/M Q&A - History, we were very happy to see that they had answered almost all of our questions.  

From my own personal experience, we do have an issue with CC.  We get patients that tell the nurse one thing and then when the physician gets in the room, it is something different.  At this point, the providers have been very receptive and are trying to alter their routine and restate the CC as the first line of their documentation.


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## coder911

Rebecca, 
Thank you so much for listing these source documents. I have been on the hunt for something substantial enough that I could deliver to our EMR vendor and multiple providers. 
This is an industry standard that has been hard to "prove" to other entities due to the "lack" of specificity in the 1995/97 guidelines. Apparently it allows some individuals enough room to argue that because it does not specifically state "ancillary staff *can't* document the HPI" - means that they can defend that position in court.
I believe this issue needs direct attention - exponentially so now with EMR becoming so relevant.
Thank you again, cheers!


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## RebeccaWoodward*

coder911 said:


> Rebecca,
> Thank you so much for listing these source documents. I have been on the hunt for something substantial enough that I could deliver to our EMR vendor and multiple providers.
> This is an industry standard that has been hard to "prove" to other entities due to the "lack" of specificity in the 1995/97 guidelines. Apparently it allows some individuals enough room to argue that because it does not specifically state "ancillary staff *can't* document the HPI" - means that they can defend that position in court.
> I believe this issue needs direct attention - exponentially so now with EMR becoming so relevant.
> Thank you again, cheers!



Happy to help~

Update to date Palmetto link...

http://www.palmettogba.com/palmetto...Asked Questions~EM~8EELQE6434?open&navmenu=||


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## rthames052006

RebeccaWoodward* said:


> Laura,
> 
> Typically, I see "eye to eye" with you but not in this case.  CMS has made it clear, or so to me, that ancillary staff cannot document the CC.  There are many other articles and well known coding guru's that agree with this ideology.  I don't know about your carrier but my local carrier always emphasizes this requirement at our conferences.
> 
> DG-*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.*
> 
> AAOS---  "The chief complaint (CC) and history of present illness (HPI), however, are different from the rest of the components in the patient history. Reporting and documenting the CC and HPI must be done by the physician or NPP reporting the service."
> 
> http://www.aaos.org/news/bulletin/oct07/managing8.asp
> 
> I'm not suggesting that ancillary staff can't write down the reason for the visit but it's very clear that the physician must acknowledge/add/sign...something in addition to this comment.
> 
> "To agree or not to agree"...at least we can still have a healthy discussion whether *we* agree on the subject or not.



Rebecca:

I agree with you on this 100%.  We've also had this discussion.  Our MA's/ Nurses do document the " reason for visit" and the provider documents the CC and does the HPI section.  

It surprises me ( at times ) how a patient will tell the MA/nurse the reason for the visit and it differs from what they actually tell the provider!  I've seen it plenty of times where the MA will go in and ask the patient why they are here/problem and they tell the dr the "real reason" why they are here, not sure if they maybe embarrassed or what but I just thought I'd add my 2 cents on this one. 

With CMS stating what the MA or ancillary staff can document tells me that whatever isn't listed there can't be documented by the ancillary staff/MA. IF it were it would be stated ( just my opinion).


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