# Chief Complaint and HPI documentation



## mchristner (Mar 31, 2010)

It is my understanding that chief complaint and HPI _*MUST*_ be documented by the physician and *not* the ancillary staff.  I work in a primary care physicians office and we must explain this to our staff because right now, our nurses are the ones writing the chief complaints and HPI.  Could anyone possibly help me find this rule clearly stated somewhere to share with the staff here?  What I am finding is a little unclear and I would like it in black and white to share (and be sure I am correct).

Thanks!!!!


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## LTibbetts (Apr 1, 2010)

You are correct!

It is stated pretty clearly in the 1997 & 1995 documentation guidelines (DG's). You can find them at the website below.

http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp

Also, maybe try to do a search under one of the posts for documentation guidelines or HPI and see what comes up.


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## RebeccaWoodward* (Apr 1, 2010)

You are correct...the HPI must be completed by the provider.  As Leslie pointed out, there are many threads that can be located in the search engine for links, examples, etc.

Now...the chief complaint.  I have always had the mentality that the CC was a part of the HPI; therefore, required *provider* documentation.  This is one area that you will find debatable amongst other coders. I attended a Medicare conference yesterday and presented this question to our medical director.  He agreed that the CC must be recorded by the provider. * If *the CC was recorded by ancillary staff, the physician *must *include documentation that he read/acknowledged the CC...whether by initialing or expanding on the chief complaint.


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## jdibble (Apr 1, 2010)

*Still not sure...*

Does anyone have any other documentation that states *directly* that the physician must document the HPI and not the ancillary staff? I checked the 95 & 97 guidelines on the site as suggested and all I see is statements saying that the ROS and PFSH can be recorded by the ancillary staff or by the patient filling out forms. It does not directly state that the doc needs to complete the HPI - it is only implied. 

My nurses usually document an HPI and then the doctor checks a box stating "the above note reviewed and confirmed". He then rewrites a portion of what the nurse stated sometimes adding more info. If he didn't document enough elements, we take some of the elements from the nurse's statement, as long as he has checked the box, to complete the HPI level. We were told before that this was acceptable. If not, I need some proof to bring to the director and to advise our docs that they need to be doing more work!

Thanks for the input.

Jodi Dibble, CPC


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## LLovett (Apr 1, 2010)

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

http://www.wpsmedicare.com/part_b/education/historyem_handout3.pdf

I don't know who your carrier is, but above is from WPSMedicare. They have a lot of good info on E/M on their site.

Laura, CPC, CPMA, CEMC


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## jdibble (Apr 2, 2010)

Thanks for the info. Your carrier is specific where our carrier, Highmark, does not have any statement about the physician having to complete the HPI. When asked, they imply that it is not necessarily the case - they will not say yes or no! Very confusing, especially when I am the one who has to teach our docs and I want to make sure they are documenting what they need to do!


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## SCanterbury (Apr 5, 2010)

From Part B News, 6/11/07 issue:

_In an email to Part B News, CMS confirmed that the strong guidance to that effect recently posted on Noridian’s website was, in fact, official agency policy.

Noridian instructed physicians in the carrier’s 13 states that “reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the [HPI]. An example of unacceptable HPI documentation would be “I have reviewed the HPI and agree with above.” The Noridian posting echoes recently published guidance
from Palmetto GBA and Wisconsin Physician Services, as several readers pointed out.

“The Noridian [Web site] is correct,” a CMS official wrote in response to a Part B News request for confirmation._​
Specific allowance is made for individuals other than the billing provider to obtain and document the ROS and PFSH subcomponents of History. In the '97 guidelines, allowance is made for ancillary staff to obtain and document the vitals (with virtually all Medicare carriers allowing this when '95 guidelines are used as well).

This is mentioned in the 10/24/05 Part B News, where it says:

_"The entire set of guidelines were written to identify the physician work [emphasis added] necessary to perform and document" the medical record for an E/M service, an E/M guru from CMS tells Part B News. The official says those are - as Buechner points out - ROS, PFSH and vitals."_

So unless the guidelines specifically allow someone else to do something, the work they describe is understood to be physician work only.

Think about it. The Guidelines already say that it's ok for ancillary staff to perform the ROS and PFSH components. If they are also allowed to take both the CC and HPI, then the doctors would be completely removed from history-taking, other than writing a short note saying that they reviewed what history a nurse took. Many doctors say that the history is the most important part of a visit. There is no way that permission will be given for ancillary staff to do all of it, and this permission wasn't given in the guidelines.

Seth Canterbury, CPC, ACS-EM


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