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Old 04-15-2009, 06:24 AM
uksjmartin uksjmartin is offline
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Default Documentation of Chief Complaint

Can ancillary staff document the chief complaint?
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Old 04-15-2009, 06:36 AM
RebeccaWoodward* RebeccaWoodward* is offline
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No..Must be MD.

Ancillary Staff and Patient Histories

Q What portion of a visit can ancillary staff perform and document? Can they perform and document the history of present illness (HPI) or chief complaint (CC) if I read their documentation and notate that I have done so and agree with it?

A According to the 1995 and 1997 E&M documentation guidelines, the only portions of the history that may be recorded by the ancillary staff of a physician are the Review of Systems and Past/Family/Social History, and those portions must be reviewed by the physician. The physician must also write a statement supplementing or confirming the information recorded by the ancillary staff.

CMS recently clarified that only the physician or nonphysician practitioner who is conducting the E&M visit can perform the HPI and CC, stating that this is physician-level work and shall not be relegated to ancillary staff.

The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded, or scribed, and write a notation that she reviewed it for accuracy and did perform it, adding to it if necessary and signing her name.

Last edited by RebeccaWoodward*; 04-15-2009 at 06:45 AM.
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Old 04-17-2009, 07:12 AM
LLovett LLovett is offline
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Can you please post the link to CMS stating this?

Thanks

Laura, CPC
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Old 04-17-2009, 07:28 AM
RebeccaWoodward* RebeccaWoodward* is offline
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Ohio Part B Carrier
What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an Evaluation and Management encounter? Can ancillary staff act as a scribe for a provider?

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 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/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.

Scribe (E/M Services):

If ancillary staff is present while the physician is gathering further information related to the HPI or any of the three key components, he/she may document (scribe) what is dictated and performed by the physician or NPP. The physician needs to review the information as it is written, documented, recorded or scribed and write a notation that he/she reviewed it for accuracy, add to it if supplemental information is needed, and sign his/her name. The name of the scribe must be identified in the medical records.

Ancillary staff does not need to be employed by the physician (example: hospital employees).

Resources:

CMS 1995 & 1997 E/M Guidelines - http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
Palmetto GBA E/M Help Center, located in "Articles":
Ohio: http://www.PalmettoGBA.com/boh
West Virginia: http://www.PalmettoGBA.com/bwv
South Carolina: http://www.PalmettoGBA



http://www.palmettogba.com/palmetto/...20a%20provider

http://www.wisconsinmedicalsociety.o...cation/faq#q16
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Old 04-17-2009, 07:37 AM
RebeccaWoodward* RebeccaWoodward* is offline
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Also......

A common question amongst coders that routinely deal with E&M services.

The E&M Guidelines specify which elements can be recorded by someone other than the physician. "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." Standard legal and rule making logic "when something is omitted from a list of what is approved, the omission is forbidden and can't be included".

If you review the April 1996 CPT® Assistant describing the elements of an HPI. You will see the definitions of the HPI elements always refer to the physician or clinician

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.

There is also this FAQ that was published in the November 2003 Communiqué.

Frequently Asked Questions (FAQs)

Who can perform the History of Present Illness (HPI) portion of the patient's history? (04/01/04)

The history portion refers to the subjective information obtained by the provider or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the history of present illness (HPI) portion of the patient's history. Only the provider can perform the HPI.

From FAQs at the WPS site
Q. If the nurse takes the History of Present Illness (HPI), can the physician then state "HPI as above by the nurse" or just "HPI as above" in the documentation?
A. No, the physician needs to fully document the HPI.


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

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.
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Old 04-17-2009, 11:10 AM
LLovett LLovett is offline
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I don't have a problem with the HPI being done by the provider. I do have a problem with the statements regarding CC.

HPI and chief complaint are not the same thing.

Is there something that specifically states the provider has to obtain the cc? The only thing I find on cc is that it is required at all levels of history and that it is usually in the patients own words.

Thanks,

Laura, CPC
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Old 04-20-2009, 07:53 AM
RebeccaWoodward* RebeccaWoodward* is offline
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Laura,

Typically, I see "eye to eye" with you but not in this case. CMS has made it clear, or so to me, that ancillary staff cannot document the CC. There are many other articles and well known coding guru's that agree with this ideology. I don't know about your carrier but my local carrier always emphasizes this requirement at our conferences.

DG-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.

AAOS--- "The chief complaint (CC) and history of present illness (HPI), however, are different from the rest of the components in the patient history. Reporting and documenting the CC and HPI must be done by the physician or NPP reporting the service."

http://www.aaos.org/news/bulletin/oct07/managing8.asp

I'm not suggesting that ancillary staff can't write down the reason for the visit but it's very clear that the physician must acknowledge/add/sign...something in addition to this comment.

"To agree or not to agree"...at least we can still have a healthy discussion whether we agree on the subject or not.
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Old 04-20-2009, 09:38 AM
LLovett LLovett is offline
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Rebecca,

I don't mean to be argumenatative but this could have a huge impact on hundreds of providers at my facility alone, and until I have something in hand from CMS clearly stating they have to do it, I am not comfortable telling them that is the way it needs to be done.

Myself and other coders I work with are having a hard time seeing how this is required based on the guidelines, and my facility will accept nothing less than requirements that come directly from CMS or WPSmedicare.

On another post regarding this topic, an article by Risë Marie Cleland was quoted as a source supporting this. I emailed her and she could not find supporting information from CMS, she sent me links to Noridan and Palmetto GBA. I just got off the phone with Noridian, they clearly state it came from CMS in their article but they can't direct me to their source. She is supposed to do more research and call me back. As soon as or if I ever get a call back I will post the response I get.

I am a total stickler for compliance and I will make sure all the providers I am responsible for do everything per the guidelines that apply to us. I just have to prove it applies to them in order to keep the peace.

Thanks for taking time to post your sources!

Laura, CPC
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Old 04-20-2009, 11:09 AM
RebeccaWoodward* RebeccaWoodward* is offline
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No no...I didn't take your comments as argumentative. Unfortunately, the coding/compliance world can be clear as mud... Someone tossed this excerpt from Noridian into my lap....

Medicare Part B

Evaluation and Management Clarification

The Centers for Medicare and Medicaid Services (CMS) has clarified that only the physician or non-physician practitioner (NPP) who is conducting the evaluation and management (E&M) visit can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff.

Noridian Administrative Services (NAS) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when “physician” criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name.

Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be “I have reviewed the HPI and agree with above.”

Applies to the states of: AK, AZ, CO, HI, IA, MT, ND, NV, OR, SD, UT, WA & WY.

Effective Immediately

This article was posted to the Updates section of the Noridian website on May 21, 2007.

Posted: 5/21/2007 by NAS, LLC

Is this what you were referring to?
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Old 04-20-2009, 11:17 AM
LLovett LLovett is offline
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That is the one. As of yet, Noridian still hasn't called me back with the source document they are siting. I find it interesting that they don't link to it from the article. WPSmedicare is always really good to put a link to the CMS source document.

Laura, CPC
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