Cardiology Coding Alert
Limit HPI Collection to Billing Physician
Question: I’ve heard the physician needs to document HPI. Is validating an HPI taken by other staff sufficient?
Kansas Subscriber
Answer: No, the billing physician should document the history of present illness (HPI) herself.
The Part B MAC for your state of Kansas, WPS Medicare, has posted a helpful Q&A at
www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml.
In Question 19, WPS specifically states that having the physician document “HPI as above by nurse” is not sufficient: “The physician billing the service must document the HPI.”
Ancillary staff may record the review of systems (ROS) and past, family, and social history (PFSH) for physician review and validation, according to CMS’s 1995 and 1997 Documentation Guidelines, available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html.
Cardiology Coding Alert
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