# Who Can Document the Chief Complain



## sgann

I have been to several conference's lately that have indicated that only the Doctor/Proivder of services can document the chief complaint.  I have brought this back to my peers and they want proof.  The only proof I have is the 1995 documentation guidelines that indicate that ancillay staff can document the ROS and PFSH.  They say that is subjective and they want something from an accredited organization, CMS, AAPC, Ect to back up that statement.  Can I get some help.


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## Lisa Bledsoe

The 6/11/07 issue of Part B News addresses this issue.  It also references the Noridian Medicare web site regarding their requirements.


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## dmaec

lol.. I've tried to comment on this issue a few times and keep deleting my post - I just sit here and shake my head, I don't get it.  I don't get why it's an issue... I just can't understand it..


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## sgann

It is an issue for me because I audit the provider charts and I need to know for auditing purposes.


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## Lisa Bledsoe

The chief complaint (i.e. "ear pain") may be noted by the ancillary staff, but the actual HPI must be documented by the provider.


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## dmaec

yes, sgann - I know it's an issue for you...and others too - but I don't understand why it is. (it's nothing against you or your question) I just don't understand why it's a problem - doesn't the physician document/dictate the full care provided?  it's not like we carve anything out and give credit/charges to the person who does the CC - or ROS or whatever - I think because I haven't come across this issue with my providers, I don't understand why it would be an issue at all..? - LOL this is why I kept deleting my other posts! "I" can't explain myself!


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## sgann

*Lisa*

Can you please give me the back up documentation to your statement.  I need this in writing from CMS, AAPC, AHIMA or an organization.  My peers will not accept responses from a forum or list serve.  On the intelicode forum Jan Rasmussen CPC auditor states the ancillary staff can document the CC but that the provider has to restate it in the HPI.  This idea is coming from the 1995 and 1997 CMS guidelines that states ancillary staff can do the ROS and PFSH which implies that is all they can do.  The DG in the guidelines states that the CC HPI and ROS can be all in one or seperate.  That is why they are stating that the CC has to be restated in the HPI by the provider to count.

I don't know, I have been doing this for at least 2 years and this is the first time I have ever heard this.


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## Lisa Bledsoe

sgann said:


> Can you please give me the back up documentation to your statement.  I need this in writing from CMS, AAPC, AHIMA or an organization.  My peers will not accept responses from a forum or list serve.  On the intelicode forum Jan Rasmussen CPC auditor states the ancillary staff can document the CC but that the provider has to restate it in the HPI.  This idea is coming from the 1995 and 1997 CMS guidelines that states ancillary staff can do the ROS and PFSH which implies that is all they can do.  The DG in the guidelines states that the CC HPI and ROS can be all in one or seperate.  That is why they are stating that the CC has to be restated in the HPI by the provider to count.
> 
> I don't know, I have been doing this for at least 2 years and this is the first time I have ever heard this.



Try this link to Noridian/CMS:
https://www.noridianmedicare.com/sh.../Evaluation_and_Management_Clarification_.htm

Is that helpful?  I can't give you the link for Part B News, you have to be a subscriber.  But the PBN article is based on this statement by Noridian.
Lisa


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## dmaec

http://www.wpsmedicare.com/part_b/publications/em_history.shtml
on this link as well it states: 

The HPI may only be obtained by the provider, and may not be obtained by ancillary staff. 

The CC/HPI are basically one in the same - so why would anyone separate to a point where an ancillary staff documents the CC but the provider does the HPI?   The CC rolls right into the HPI - It's "one" of the "three" sub- components under the HISTORY COMPONENTS.  CC/HPI  & ROS & PFSH.


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## FTessaBartels

*Go back to your source*

Sherry,
You indicate that you've been to several conferences lately where this was brought up. Perhaps one of those conference speakers/leaders has the proof your peers are requesting?  

Good luck,
F Tessa Bartels, CPC, CPC-E/M


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## Candice_Fenildo

What about providers that are using EHR. and have Ancillary Staff scribing for the physicians in the room?????


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## dmaec

hi, just thought I'd share this info:  From Progressive Healthcare Conference 07/23/08 - perh CMS E/M guidelines:
ancillary staff may document ROS and PFSH
PROVIDER must personally document HPI
Chief Complaint may be inferred 

I think I said that in one of the earlier posts - basically HPI/CC same
Confirmed at this meeting   and on the CMS website...


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## geigerk

Sherry,  The answer is the Documentation guidelines you are referring to...Only the ROS and PFSH can be documented by ancillary personnel, because that is stated as allowed.  Obviously, they do not say that about HPI, Exam or MDM.  Documentation guidelines also allow you to have the CC "inferred" from the HPI.  So, while an ancillary person can document in the part of the medical record that is the CC, if you do not have anything out of the HPI to "infer" a CC, you do not have one.  (In that case you would not have much of an HPI either.)  The only other resource you may want to look at would be the CPT Assistant Archives, back from when the DG were first published April of 95 or 96...They publish the reasoning behind these codes.  Something I have not been able to get ahold of myself, but I really want to read those.  Hope this helps.


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## RebeccaWoodward*

Last Q/A addresses this question~

http://www.physicianspractice.com/index/fuseaction/articles.supplementDetails/articleID/1196.htm


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