Confirmed: Billing Provider Must Document the HPI
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.