Wiki HPI Documentation

[AliMontone]

I just started working as a practice manager for a solo practice specialist who refuses to listen to me. He is making his staff do all chart documentation at intake including doing the HPI for him! Even going so far as to have them select the bullets in the templates for location, severity, timing, etc. I have shown him in black and white the CMS guidelines stating that ancillary staff cannot perform or document the HPI, the physician himself must do this. This is a huge problem for me. His response was do it my way or quit. I guess my question is, has something changed and is ancillary staff now allowed to perform and document the HPI or am I correct and we are headed for huge problems down the road if an audit is to occur? If anyone has any information (more current) either way, I would appreciate it. We have an EMR and I tried to explain that everything is documented as to who performs each action and it is even time stamped. His answer was again, do it my way or quit. That, right now, is not an option.

 

[mhstrauss]

I just started working as a practice manager for a solo practice specialist who refuses to listen to me. He is making his staff do all chart documentation at intake including doing the HPI for him! Even going so far as to have them select the bullets in the templates for location, severity, timing, etc. I have shown him in black and white the CMS guidelines stating that ancillary staff cannot perform or document the HPI, the physician himself must do this. This is a huge problem for me. His response was do it my way or quit. I guess my question is, has something changed and is ancillary staff now allowed to perform and document the HPI or am I correct and we are headed for huge problems down the road if an audit is to occur? If anyone has any information (more current) either way, I would appreciate it. We have an EMR and I tried to explain that everything is documented as to who performs each action and it is even time stamped. His answer was again, do it my way or quit. That, right now, is not an option.

You are absolutely correct! Nothing has changed; ancillary staff can only document PFSH, ROS, and vitals. Doing things his way will lead to HUGE problems if he is audited. I'm attaching a link to the most current doc. guidelines (which you've probably already seen), showing current as of Nov 2014.

http://www.cms.gov/Outreach-and-Edu.../Downloads/eval_mgmt_serv_guide-ICN006764.pdf

HTH!

 

[LLovett]

The provider appears to be displaying a very concerning attitude with regards to compliance. If the guidelines don't inspire him to follow the straight and narrow maybe you could try sharing info from the OIG. They publish all the corporate integrity agreements online as well as all their enforcement actions.

The following links are to a case and CIA that may be of interest to your provider. Since the HPI is not being performed and documented by the provider it can't be utilized to level the visit. If it is being utilized, when audited this could result in what is considered overcoding. Overcoding is the problem with the providers discussed in these documents.

http://www.justice.gov/usao-ndal/pr...n-settle-allegations-inflated-medicare-claims

https://oig.hhs.gov/fraud/cia/agreements/American_Family_Care_03122014.pdf

Good luck,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC

 

[AliMontone]

Thank you both for your replies. It is a very difficult situation to manage. I unfortunately do not think he is willing to comply and my only option will be to resign. I cannot allow this to continue under my management. He thinks he is untouchable. I know better. I have been through and have passed many random audits by insurance companies, as well as being audited 3 years in a row for all 3 physicians for Meaningful use, passed as well, at my last practice due to digilence in record keeping and training of the physicians and staff, etc., and have even reminded him of this. He still responds with "my way or quit." I now have a sneaking suspicion why he "decided" to leave his group and start his own practice. Guess I should have researched further before signing on the dotted line.