# HPI documentation and Audits



## grothrock (Nov 19, 2010)

My providers and pushing to have the MA's and LPN's document the HPI portion in EMR to speed up work flow, I have provided them with the Medicare Part B Evaluation and Management Clarification form that states:

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
Evaluation and Management Clarification Page 1 of 1
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They do not feel that having the MA's or LPN's document the HPI is illegal and there isn't audit risk because they are re-addressing the items in the HPI.  From an audit point of view how will this be addressed if it is discovered to be the practice?


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## btadlock1 (Dec 2, 2010)

Remind them that all they have to document is 4 little tiny HPI elements, and give them examples of questions to ask that lead the patient to use describe why they're there. (What hurts?-location When did it start hurting?-duration Describe the pain.-quality How often does it bother you?-timing - Have you taken anything for it?-modifying factor, etc.) It's really not that hard, and if they don't do it, then they don't get credit for it in the audit. The best that documentation can be used for is ROS, and without any HPI more ROS isn't going to help the overall code selection. Hope that helps...

Brandi Tadlock, CPC, CPMA


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## Lisa Bledsoe (Dec 3, 2010)

*Physician/NPP must document HPI*

http://www.trailblazerhealth.com/Publications/Questions and Answers/E-MWBTQA09-30-09.pdf
see pages 3-4


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