Confirmed: Billing Provider Must Document the HPI

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  • May 19, 2014
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Question: Is it acceptable for ancillary personnel to obtain and record elements of the history of present illness (HPI) portion of the history component? Chapters 12 and 15 of the CMS web manuals do not reference the HPI—only the review of systems (ROS) and past/family/social history (PFSH).
Answer: Per CMS rules and the 1995 and 1997 Evaluation and Management Documentation Guidelines:

The Review of Systems and the Past, Family and/or Social History may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, the physician must add a notation supplementing or confirming the information recorded by others.

Most payers, auditors, and other professionals interpret this instruction to mean that the HPI has to be performed by the physician, as it is not specifically mentioned as something the provider may delegate. For example, Palmetto GBA requires:

 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 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.
Many other payers, as well as provider advocacy organizations, specify similar guidelines.
Bottom line: The billing provider should be the one to collect and document the patient’s HPI. The ROS, PFSH, and vital signs may be recorded by someone other than the provider.

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John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “Confirmed: Billing Provider Must Document the HPI”

  1. CP says:

    I have always audited based on this guidance. Although Palmetto specifically clarifies this, does anyone have specific guidance from CMS or NGS?

  2. ST says:

    “Physician must write a statement that it is reviewed and must correct or add to it”
    How do you do this in an EHR, free type next to the statements in note?

  3. Judy Breuker says:

    WPS Medicare J8 Mac Part B (Michigan and Indiana) and J5 MAC Part B (Iowa, Kansas, Missouri and Nebraska) under “History Element of E/M Q&As” state:
    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.
    I hope this is helpful.

  4. Kim says:

    We have a company telling our providers that it’s okay for the ancillary staff to take the HPI, and then when the physician comes into the room, the ancillary staff will restate the HPI to the physician in front of the patient and then that it can then be used by the physician as if he took it. Any thoughts on this one? I still say NO, but wonder if anyone from Michigan has any experience with something like this.

  5. Joan G says:

    I think you need to be careful about “assuming” what’s going on between the ancillary staff member and the physician in the scenario you described. There is absolutely nothing that prohibits a staff member from asking HPI related questions. Think about the last time you went to the doctor for an upper respiratory infection. Did the nurse who put you in the room ask you how long you’d had the symptoms? (duration) Whether you had been running a fever? (associated signs and symptoms). If you had said that you also had a cough, did the nurse ask you whether or not it was a productive cough (quality)? As you can see, nurses ask HPI questions all the time in the normal course of rooming the patient!! You don’t need to worry that the nurses were doing anything illegal or practicing medicine outside of the scope of their licensure when they asked these questions.
    That said, the FORMAL HPI (ie, the information that the physician gets credit for) needs to be the information he/she personally gathered from the patient — EVEN when it’s information that he’s confirming with the patient is true from the info the nurse gathered. What it sounds like is going on in the scenario you’re describing is that instead of the nurse writing all this down for the physician to read before going into the room (which the physician would then need to confirm with the patient by asking the same questions again), instead, the nurse is succinctly VERBALLY paraphrasing the information gathered from the patient. The patient then has the opportunity to correct anything the nurse got wrong and the physician has a chance to ask clarifying questions. When that part of the assessment is done, what the physician would record for the HPI is THEIR OWN synopsis of ALL of the HPI information gathered.
    The key, though, is that the physician has to be the one deciding what information ultimately gets recorded in the medical record for the physician’s HPI. It can’t be the nurse recording HER HPI and the physician then simply going on to do the exam and the rest of the visit.
    One thing to also keep in mind is that sometimes the patient can offer a detailed HPI without the physician asking a single question other than “Why are you here today?” Personally, as a patient, I’m guilty of that! (a casualty of reading too many medical record notes in my career, I think – lol!). Seriously, I may tell the physician everything he needed to know about chronology of my problem — and do it so thoroughly, that I’ve answered every HPI and ROS question the physician would have wanted to know about my condition with that one simple question “why are you here today?”! (of course, that’s only going to happen for simpler problems, but still, I think you know what I mean).
    The point I’m trying to make is that physicians don’t get paid for how much oxygen they use in asking questions during the interview of the patient. They get paid for how much information they needed to gather in order to figure out what’s wrong with the patient and what to do about it (ie, they get paid for their cognitive work). If I as the patient (or in your example, the nurse as the preliminary gatherer of some of the history information) simply “prime the pump” for the physician with information we think the physician wants to know, it’s still the physician’s responsibility to confirm that information AND to ask whatever additional questions that he/she needs to get all of the HPI information necessary for the presenting problems.
    Again, I’m *not* saying that the physician doesn’t do his/her own HPI. The idea of the verbal presentation of preliminary HPI information gathered by the nurse when rooming the patient simply seems to me to be an efficient way for the physician to gather some of the HPI information. Again, the caveat here, though, is that the physician decides what gets to be documented as the final HPI for the work-up of this encounter.
    I’d have a real problem if the nurse documented the HPI and the physician simply just agreed with it without having any evidence that the physician did more than read it. But if the physician verbally gets HPI information from the nurse and patient together, then obtains whatever additional information is needed from there, the overall HPI is still HPI information the physician has gathered, right?

  6. Jennifer says:

    Does anyone have information from Novitas or CMS (in writing) on this? I have an FAQ from Novitas, but it says “provider” and administrator is saying that since it doesn’t say “physician” that it could mean ancillary staff.

  7. Syreeta says:

    Good ideas ! I was fascinated by the info – Does someone know if my business would be able to find a template USSS SSF 1604 document to complete ?

  8. ASaiz says:

    You’ll find a lot of suggestions and better answers to your question in the Member Forums.

  9. Marisol Ramos says:

    Does CMS allow the HPI to be documented under the assessment? Wouldn’t the extended history be incomplete if that component is missing?

  10. Josh W says:

    We have our Rooming CMA transcribe a PHQ Score (clinically validated screening tool) into the HPI, which the provider then sees and reviews when they go into the room. What do folks think about this “transcribing” of screening resulting into the HPI for the provider to assess? Does that transcription need to be by the provider’s hand?

  11. Penney Greene says:

    I know that the provider must be the one that documents the HPI, but can anyone tell me if it is acceptable for the HPI to state: “Reported by Patient”. I am seeing this a lot in different EMR systems and was told by one provider that it was required for their particular EMR.. I can’t find anything in the documentation guidelines about this.