Wiki HPI Taken by a Nurse

[Sdinola]

Does anyone have the written rule and source stating the physician billing a service must document the HPI?

 

[a.montaruli@gmail.com]

The only thing I have in writting came from the CEMC Study Guide as well as the E/M Modules offered by AAPC that states the HPI MUST be documented by the Physician. The only thing the nurse may document is the ROS, but obviously still needs to be reviewed by the doc.

Hope this helps,
Andrew

 

[RebeccaWoodward*]

Does anyone have the written rule and source stating the physician billing a service must document the HPI?

Our MAC is clear on this...

What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an evaluation and management (E/M) encounter? Can ancillary staff act as a scribe for a provider?

Answer:
Ancillary staff may only document:

•Review of systems (ROS)
•Past, family and social history (PFSH)
•Vital signs
These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.


http://www.palmettogba.com/palmetto...Asked Questions~EM~8EELQE6434?open&navmenu=||

 

[MikeEnos]

I'm not sure who your local MAC is, but their website should give you some clear requirements on that.
Here's some reference from WPS:

Q 18. Who can perform the History of Present Illness (HPI) portion of the patient's history?
A 18. The history portion refers to the subjective information obtained by the physician or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the HPI. Only the physician can perform the HPI.

Q 19. If the nurse takes the HPI, can the physician then state, "HPI as above by the nurse" or just "HPI as above in the documentation"?
A 19. No. The physician billing the service must document the HPI.

According to the CMS Evaluation and Management Services Guide:

The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by
the patient. To document that the physician reviewed the information, there must be
a notation supplementing or confirming the information recorded by others.

Sometimes there is varation from MAC to MAC, but Todd Thomas did some research in a great article on codepedia.

Most experts agree that the absence of AMA or CMS coming out and saying that someone other than the physician can do the HPI means that it must be performed by the physician. There is also the following quote from Dr Bart McCann to show the physicians that they are expected to perform the HPI. "The physician must write an HPI Statement. It is understood the residents and other ancillary staff may collect some of this information as well but this does not absolve the physician of the duty to verify the information and summarize the HPI statement his / herself. The ROS past family and social history maybe obtained and documented by someone other than the physician. However, the physician must review and comment on the information, whereas in the HPI the entire thing must be done by the physician." Quote from Bart McCann, MD Executive Medical Director HCFA Printed in Physician Practice Coder, December 1997.

and the grand finale:

The issue has been clarified several times with Cathleen Scally at CMS and she has verified that HPI must be done by the billing provider. There was a past discussion about a possible misquote of Dr. McCann in a 1998 article that indicated that he said it was acceptable for someone else to document the HPI as long as the physician reviews/adds to it.

The quote in question was forwarded to Ms Scally who then wrote to Dr. McCann to determine whether or not he had been misquoted in the publication, pointing out that CMS has never permitted anyone but the physician/NPP who is performing the E/M to do the HPI. She also noted that in certain circumstances like an ER where a triage nurse takes the initial chief complaint and perhaps even an HPI it is required that the physician/NPP of record must actually review the chief complaint and HPI with the patient and write it him/herself and not just sign what an ancillary employee may have recorded.

Dr. McCann's response to Ms. Scally was clear and unequivocal:

"Kit, I totally concur with your interpretation. What kind of doctor doesn’t take his/her own history?"

That should make it perfectly clear. All of the HPI elements must be taken from the Doctor's notes.