I posted a similar thread on the "general discussions" page, but thought maybe I would post here as well.
I discovered this in the course of auditing my providers charts. In our practice the Medical Assistants enter the chief complaint info in the EHR, this information is considered the HPI.
The provider will then review and add his observations and other information obtained from the patient. If however, the medical assistant obtained a very good HPI, and the provider determined there was nothing further to add, he/she will continue on to the ROS. Unfortunately, simply clicking on and reviewing the HPI without adding any of his/her own comments, leaves the medical assitants name next to the HPI in the EHR record. It looks as though the provider did nothing with the HPI. (we have since changed this function in the EHR, so that reviewing the record, changes the documentation to the provider.)
Now, I know that the HPI is one of the three components of documentation, and it's considered not done if not documented by the provider.
I also know that you only need to meet 2 of the 3 components if it is an established patient. If the exam and MDM are good enough to meet the code billed is the documentation good enough to pass an audit? Or should we be considering reimbursing Medicare on all those visits, documented with a medical assistants name next to the HPI?
I would really appreciate as much feedback on this as possible.
I discovered this in the course of auditing my providers charts. In our practice the Medical Assistants enter the chief complaint info in the EHR, this information is considered the HPI.
The provider will then review and add his observations and other information obtained from the patient. If however, the medical assistant obtained a very good HPI, and the provider determined there was nothing further to add, he/she will continue on to the ROS. Unfortunately, simply clicking on and reviewing the HPI without adding any of his/her own comments, leaves the medical assitants name next to the HPI in the EHR record. It looks as though the provider did nothing with the HPI. (we have since changed this function in the EHR, so that reviewing the record, changes the documentation to the provider.)
Now, I know that the HPI is one of the three components of documentation, and it's considered not done if not documented by the provider.
I also know that you only need to meet 2 of the 3 components if it is an established patient. If the exam and MDM are good enough to meet the code billed is the documentation good enough to pass an audit? Or should we be considering reimbursing Medicare on all those visits, documented with a medical assistants name next to the HPI?
I would really appreciate as much feedback on this as possible.