Wiki History documented by ancillary staff

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PennyG

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CC and History are documented by ancillary staff. I know the provider must document this. Provider has documented comprehensive ROS and PFSH. My question is can an e/m even be charged in this instance? I am doubting myself.
 
If by "History," you are referring to HPI, you are right to doubt. ONLY the PCP can document this

CC, PFSH, and ROS can be documented by anyone, but not the HPI
 
If this is a new patient then you cannot bill, as you need 3 of 3 components. Established you only need 2 of three so you could bill.
 
So, Yes, according to CMS, the HPI must be asked and recorded by the provider.

There is a Q&A on the NGS Medicare website that discusses billing an equivalent established patient visit when some required documentation for a new patient visit is missing.

https://www.ngsmedicare.com/ngs/port...hed patients

Question: When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

Answer: An initial level of service requires 3/3 elements. If only 2/3 elements are present, the service can be billed as a subsequent service. Updated 6/9/2017



Would all Medicare carriers accept this? No. Would a commercial accept this? No.

But it's an interesting thought...
 
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