The guidelines don't specifically mention which parts of the visit must be performed by the billing provider (physician or NPP). Instead, CMS has indicated that the work described in the guidelines should be understood as physician (or NPP) work except when specific allowance is made otherwise.
Specific allowance is made for individuals other than the billing provider to obtain and document the ROS and PFSH subcomponents of History. In the '97 guidelines, allowance is made for ancillary staff to obtain and document the vitals (with virtually all Medicare carriers allowing this when '95 guidelines are used as well).
This is mentioned in the 10/24/05 Part B News, where it says:
"The entire set of guidelines were written to identify the physician work [emphasis added] necessary to perform and document" the medical record for an E/M service, an E/M guru from CMS tells Part B News. The official says those are - as Buechner points out - ROS, PFSH and vitals.
So by omission of any specific allowance, the CC and HPI subcomponents of History should be understood to represent physician/NPP work. That said, Kit Scally has made comments that indicate they would be willing to allow the CC to be documented by ancillary staff.
Per the Wisconsin Medical Society’s website (no longer appears):
5.Question: Where does it state that the physician must obtain and document the chief complaint and history of present illness?
ANSWER: For HPI (history of present illness) see WPS Part B Medicare FAQ site, under documentation. For the chief complaint (CC), it was necessary to email Cathleen (Kit) Scally, at CMS for her opinion. The answer basically states that ancillary staff may document the CC. Following is a quote from her response:
"I guess a purist would say the CC is in the realm of the physician or qualified NPP performing the E/M but in reality ancillary employees such as a triage nurse or office medical assistant will write down the presenting problem/condition why the patient is being seen. Also, in reality while an employee might write down the CC the physician or qualified NPP will generally ask the patient again why he/she is there. Saying this, I believe the CC can be asked and documented by an ancillary employee. But if the ancillary employee does not capture the CC it should certainly be asked and documented by the physician.
BUT, at the MAC level, many auditors still apply the "if no specific allowance was made in the guidelines for ancillary staff to take the CC then it must be done by the physician" rule. Kit Scally has retired, and the comments posted above are no longer accessible on the web. So in my opinion the safe course to follow for both the CC and HPI is to operate with the understanding that they must be obtained and documented by the provider.
As to whether HPI information that happens to be included with the CC can be used, there is nothing in the guidelines that says you cannot use HPI information because the doctor happened to include it in the CC field. Where does it make that restriction in the guidelines? In other words, I would credit...
CC: 2 day hx of severe stabbing pain in lower right leg
...the same as...
CC: Pain
HPI:
Duration--2 days
Location--lower right leg
Quality--stabbing
Severity--severe
This is not a double-dipping matter because nothing is being used twice. The chief complaint credited is just a version stripped of the details that will be credited properly as HPI info. Sometimes providers give lots of good information on the CC line, while others write the specific details in a separate HPI section. It doesn't matter. I've only known of one Medicare carrier that tried to say otherwise, and as far as I know, they reversed that decision.
Seth Canterbury, CPC, ACS-EM
