# Need source that HPI must be documented by the provider



## CatchTheWind (Mar 17, 2017)

I think we are all in agreement that the HPI needs to be taken by the provider, although the MA or nurse can gather a preliminary HPI which the provider then discussed with the patient.  But I need this in writing from an official source, such as CMS or CPT.  

Can anyone guide me to such a source?

Thanks!


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## nomerz (Mar 17, 2017)

Since most E&M's you'd be billing require histories that are problem focused, expanded problem focused, detailed, or comprehensive and the HPI is part of the history portion, is that not sufficient?


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## Chelle-Lynn (Mar 17, 2017)

Here are the requirements based on CMS rules.

https://www.cms.gov/Outreach-and-Ed...ork-MLN/MLNProducts/downloads/referenceII.pdf


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## ellzeycoding (Mar 17, 2017)

The logic is that the CMS document referenced above only states that the ROS and PFSH may be obtained by ancillary staff.  Since the HPI is not listed, this means that the HPI must be recorded by the provider.

On the 7th page of the document (page 115)

_• 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. _


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## CatchTheWind (Mar 22, 2017)

Is there nowhere that CMS (or any other authoritative source) explicitly states it?


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## ellzeycoding (Mar 22, 2017)

We gave the citation above.

AAPC also has an info article on it with the same reasoning

https://www.aapc.com/blog/27349-confirmed-billing-provider-must-document-the-hpi/

Backed up here...

http://www.aappublications.org/news/aapnewsmag/2016/05/31/Coding052716.full.pdf


Found this on a FAQ on a Medicare carrier website...


See #9

https://ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/evaluation%20and%20management/evaluation%20and%20management%20frequently%20asked%20questions


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## CatchTheWind (Mar 24, 2017)

That's helpful.  Thanks!

I wish that CMS itself would come out and explicitly state that the provider must take the HPI, like WPS and NGS have done in the links above (rather than requiring us to "infer" it from its absence).  It would make it easier to argue the point with the providers!


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## ndanh01 (May 31, 2017)

*HPI clarification from Noridian*



CatchTheWind said:


> Is there nowhere that CMS (or any other authoritative source) explicitly states it?



I believe this is what you are looking for... (Copied from the Noridian site for E/M clarification)  Please follow the link below for the site.

https://med.noridianmedicare.com/web/jfb/specialties/em/clarification     (copy and paste in your browser if not clickable)


Evaluation and Management Clarification


Per CMS, 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 Healthcare Solutions 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."


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## CatchTheWind (Aug 16, 2017)

Thank you all for your help with this!


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