Wiki CMS Regulations for HPI

Binghamton, NY
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Can anyone point me in the direction of where I will find rules/regulations pertaining to who may document the HPI in a patient record? My understanding is that CMS states only the physician may do so yet we are unable to locate this regulation in text.

Physicians who allow unqualified ancillary staff do the HPI are subjecting themselves to the risk of a major compensable event and a failure of care standards at best. However, the answer to your questions is state specific. Some states state that a physician may have ancillary staff document the HPI but must review for accuracy and sign off on it in order to factor it in E/M Coding. Other states have taken a firmer position and rejected the idea totally. Please find an exerpt from Medicare:

Medicare B News Issue 238 July 10 2007

Heading: Clarification
Title: Evaluation and Management Clarification

The Centers for Medicare and Medicaid Services (CMS) has clarified that only the physician or non-physician practitioner (NPP) who is conducting the evaluation and management (E&M) visit can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff.

Noridian Administrative Services (NAS) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when "physician" criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name.

Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be "I have reviewed the HPI and agree with above."

Applies to the states of: AK, AZ, CO, HI, IA, MT, ND, NV, OR, SD, UT, WA & WY.

Posted on: 7/10/2007


I hope this helps!