KStaten
Guru
Hello Everyone!
With the new 2021 E/M Documentation changes, there have been questions that have arisen in regards to requirements for the HPI and Exam. Now that these components are deemed "medically appropriate" by the provider, that leads some to think that the extra the flexibility extends into the other aspects of these components.
To my understanding, the following are true:
1) The HPI may still be documented by the ancillary staff, but the exam MUST still be documented by the provider (or scribe on his / her behalf) who is treating the patient for that visit (physician, PA, NP, etc). (?)
2) Though the documentation requirements have been reduced, both of these components (the HPI and the exam) are still required for a complete note. (?)
Am I correct? (It won't be the first or last time I have been wrong
Thank you in advance,
Kim
With the new 2021 E/M Documentation changes, there have been questions that have arisen in regards to requirements for the HPI and Exam. Now that these components are deemed "medically appropriate" by the provider, that leads some to think that the extra the flexibility extends into the other aspects of these components.
To my understanding, the following are true:
1) The HPI may still be documented by the ancillary staff, but the exam MUST still be documented by the provider (or scribe on his / her behalf) who is treating the patient for that visit (physician, PA, NP, etc). (?)
2) Though the documentation requirements have been reduced, both of these components (the HPI and the exam) are still required for a complete note. (?)
Am I correct? (It won't be the first or last time I have been wrong
Thank you in advance,
Kim