Wiki E&M Auditors Please give me your thoughts

[klgoulet1019@gmail.com]

I have a physician who is not doing the traditional HPI at the beginning of the office notes. What he does is give history within the medical record, especially in the plan/ assessment area of our EHR. I have looked for documentation that reflects he needs to do the traditional HPI which tells the chronological description of the chief complaint, but I cannot find anything that states that this is a requirement. I was hoping to get some feed back from auditors who look at physician notes to see what you think.....

 

[himanib]

First of all, HPI is subjective that is reflecting patient's narrative, and assessment and plan would be part of objective is physician's narrative -after collecting data and examining the patient, the provider makes his own assessment and plan for the patient with his expertise. Now, chief complaint must be stated at the beginning of the visit note and HPI should reflect the required elements of HPI for the assigned code. I prefer and advise my providers to identify those in the beginning of the note because that's the flow of the visit too. It helps them applying appropriate code because the thought process is clearly seen. Does your physician have the chief complaint for a visit that states the medical necessity of the visit? Does she have those HPI elements met in A/P to fulfill the requirements of assigned code?

 

[kroemer4]

History of Present Illness

Does your physician document an interval history in place of the usual HPI? Does he give you a reason why he documents HPI info in the MDM?

Or, is he possibly documenting in APSO format (versus SOAP)? There have been a lot of articles written considering the perks of APSO format in EHR, especially considering referring physicians are more interested in the Assessment & Plan versus scrolling through the Subjective and Objective portions of the note. We have an option in our EHR where the practitioners can document in APSO format. It's also helpful for mobile devices.

Further APSO reading here: http://www.ajmc.com/journals/ajac/2...f-apso-notes-across-a-major-health-system/P-2

From an auditing perspective, I would want to ensure an HPI is collected and he is the one collecting it (if he's the billing practitioner). If I cannot find the HPI in the note (separate from the MDM), I cannot count it. It's one thing if he is documenting the entire note in the A/P portion of the EMR; unfortunately, I've had instances where practitioners dictate their notes and the transcription service dumps the entire note into one header in the EMR. Even in those instances an auditor needs to be able to parse the information and not double dip.