Wiki Hpi

[cbunti]

I know the guidelines state that the HPI can not be completed by ancillary staff (nurse, technician, etc.) and MUST be documented by the physician. Some of our physician's are very slow with typing and have chosen to place a statement "As the physician I have reviewed/discussed with the patient all information completed by the patient and documented by ancillary staff/amendments have been made as needed." We use an EMR system. Would this be acceptable?

 

[MILLINRP]

This is from Noridian's website.

Medicare B News Issue 255 July 17 2009


Heading: Billing

Title: History of Present Illness Documentation



When completing the history of present illness (HPI) portion of an Evaluation and Management service (E&M), the ancillary staff, or a form completed by the patient, may only record the review of systems (ROS) and the past family social history portions (PFSH). The physician must review the information and make a notation supplementing or confirming the information recorded by others.



The HPI must be obtained by a physician during the evaluation and management service. Reviewing this information obtained by ancillary employees and writing a declarative sentence DOES NOT suffice for obtaining history of present illness.



Source: 1995 and 1997 Documentation Guidelines for Evaluation & Management Services.


Posted on: 7/17/2009
CPT codes, descriptors and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.


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