isleflow0r
New
If ancillary staff is documenting CC and HPI for an established patient would this be a "No Code" for insufficient documentation?
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Wiki Ancillary staff documenting cc and hpi
- Thread starter isleflow0r
- Start date
thomas7331
Guest
Most accepted guidelines say that the provider must document the HPI. As to what you should do when you encounter this situation, I would say that before making a coding decision, you should bring this to your supervisor or manager and get direction. Due to the financial impact and potential audit risk this can pose, it's important that they be aware that this is happening and take steps to get it corrected, as well as tell you what process they would like you to follow when you see it.
erjones147
Guest
Big time agree with Thomas re: HPI. ONLY the PCP can document that - no one else
On the other hand, you WANT your ancillary staff documenting the CC, as long as it's clear what the patient wanted to be seen for, not what anyone else thinks the patient should be seen for. Medicare has guidelines as to what is and is not an acceptable CC
On the other hand, you WANT your ancillary staff documenting the CC, as long as it's clear what the patient wanted to be seen for, not what anyone else thinks the patient should be seen for. Medicare has guidelines as to what is and is not an acceptable CC