Double-dipping

[jen11976]

Can you use the same statement for CC and HPI? For example:

HPI: Pt. here for pain in shoulder

CC = Pain in shoulder
HPI Location = shoulder


Thank you!!

 

[bechowthor]

Hey Jen!

I read it as the CC is Pain
and the location is shoulder ...

Hope this helps!

 

[Lisa Bledsoe]

Only if the provider documented that statement, not the ancillary staff.

 

[jen11976]

Thank you both!
The physician documented this portion of the note. Is there any supporting documentation that you have to back this up?
I have been trying to find something that states this. Maybe I should just assume because it's not stated anywhere, that it is ok?!?

Also, if the CC was stated by ancillary staff, then it is ok to count it for the CC?

Thanks again.

 

[LLovett]

There is a lot of debate on the chief complaint issue.

Per WPSMedicare (which they state is per CMS) the chief complaint can be obtained by ancillary staff as long as it is supported by the provider in the documentation.

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml

I fully agree with this but some Medicare carriers do not so you will need to check with your local carrier.

I agree on the break down for pain as your chief complaint and shoulder as your location. I don't think you will be able to find what you are looking for in writing though. You just have to go by the guidelines and be sure you can defend your position.

Laura, CPC

 

[Karolina]

The CC must be stated by the provider, as does the HPI. I agree with:
CC = Pain
HPI-location = shoulder
The only thing allowed to be documented by others are ROS and PFSH, but this must be reviewed/verified by the provider as well.