I am looking for documentation to provide a physician group about what is appropriate for the MA to be documenting in the electronic medical record. I have a general surgeon who has the MA do his complete HPI, ROS and Histories. The group is trying to establish a standard protocol for all. Also, he insists that they document the status of the patients chronic conditions. He is not addressing these conditions, the MA is just asking the patient whether their chronic problem is under control or not.
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Wiki Need Documentation
- Thread starter MT
- Start date
soprano
Guru
Both the 95 and 97 DGs state that "The ROS and/or PFSH may be recorded by anicillary 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."
Documentation
The office manager is most concerned with the completion of the HPI and clarifying the documentation of chronic problems for their specialty providers. Also, when the note is generated from our EHR, I don't think it specifies the provider reviewed. It appears that the provider documented everything.
The office manager is most concerned with the completion of the HPI and clarifying the documentation of chronic problems for their specialty providers. Also, when the note is generated from our EHR, I don't think it specifies the provider reviewed. It appears that the provider documented everything.
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mhstrauss
True Blue
We are having this exact same issue here in my clinic. For numerous years now, our surgeons have used PA's, NP's, MA's, LPN's, etc. to collect History info (HPI, ROS, and PFSH, along with getting vitals) from the patient before the surgeon goes into the room. The surgeon then reviews the info, performs exam and assesment/plan. However, in our new EMR (we just implemented Centricity in the last few months), it doesn't show who actually entered the HPI. All the documentation I can find regarding this states that the billing provider must get HPI himself; ancillary staff can only get ROS, PFSH, and vitals. I just talked to the lady I replaced, and she informed me that it was discussed at Medicare meetings numerous years ago, that it was OK for a qualified employee of the provider to collect the ENTIRE history...I'm awaiting any documentation she can come up with. I don't agree, based on everything I've read about this. I'm standing my ground that the billing provider has to collect HPI themselves.
Not sure if this helps
Not sure if this helps
cheermom68
Expert
Hpi
This FAQ is taken from the WPS website. I have also seen the same answer from other carriers.
http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0526_emqahistory.shtml
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.
The EHR should have an audit log which will show who actually entered the information.
LeeAnn
This FAQ is taken from the WPS website. I have also seen the same answer from other carriers.
http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0526_emqahistory.shtml
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.
The EHR should have an audit log which will show who actually entered the information.
LeeAnn
mhstrauss
True Blue
Thanks for the additional info LeeAnn. I have seen this link, along with many others that state the same thing...the billing provider must perform the HPI. We are awaiting answers from our EMR consultant on how to find the list of contributors for the EMR document, as well as from a coding consultant on the info that our past employees have, regarding a "quallified employee (usually PA or NP) collecting the HPI, then the billing provider reviewing it.
Getting sooo frustrated with this. I'm getting to where I think that I'm overthinking everything...yet the DG, along with guidelines from all the MAC's, all quite clearly (to me) state "provider must perform HPI"...