Wiki History documented by ancillary staff

[PennyG]

CC and History are documented by ancillary staff. I know the provider must document this. Provider has documented comprehensive ROS and PFSH. My question is can an e/m even be charged in this instance? I am doubting myself.

 

[erjones147]

If by "History," you are referring to HPI, you are right to doubt. ONLY the PCP can document this

CC, PFSH, and ROS can be documented by anyone, but not the HPI

 

[PennyG]

No HPI

So no HPI = no bill/claim?

 

[vhuscher]

If this is a new patient then you cannot bill, as you need 3 of 3 components. Established you only need 2 of three so you could bill.

 

[ellzeycoding]

So, Yes, according to CMS, the HPI must be asked and recorded by the provider.

There is a Q&A on the NGS Medicare website that discusses billing an equivalent established patient visit when some required documentation for a new patient visit is missing.

https://www.ngsmedicare.com/ngs/port...hed patients

Question: When documentation is missing one of the three required elements needed to bill a new patient level of service (CPT codes 99201-99205), what E&M code should be billed?

Answer: An initial level of service requires 3/3 elements. If only 2/3 elements are present, the service can be billed as a subsequent service. Updated 6/9/2017



Would all Medicare carriers accept this? No. Would a commercial accept this? No.

But it's an interesting thought...