Question HPI Copy and Paste

DavitaPhillips03

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I have a Hospitalist that copies the ER provider's HPI and pastes it into their note with "Per ER MD:" as the title. Is this allowed? My gut tells me no, but I have searched all over to find a guideline that specifically states that the provider must document in their own words, but have been unsuccessful. Any help pointing me in the right direction is appreciated.

I have been down coding their visits to a f/u code (depending on whether the pt is IP or OP at the time of service) and I want to make sure that I am coding correctly.
 

thomas7331

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Guidelines say that providers may reference other parts of a patient records for the ROS and PFSH if they document the location of the information and that they reviewed it, but this is not stated as allowed for HPI. Since the HPI is part of the provider's work for which the value of the E&M level is paid, I would agree with you that it should not be counted toward the level since they are just quoting the work of another provider that would have already been billed. Their own encounter should be based on their own work.

In your place I would also be uncomfortable reducing the levels without first making the provider and/or the practice owners, or compliance officers aware of the problem. The provider may just not realize that this is not acceptable, and if you start down-coding without making them aware and/or getting the buy-in of your management, it can have unpleasant repercussions down the road - I would bring it to someone's attention and let them know your doing this and make sure they are with you it.
 
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Pathos

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Thank you for your feed back Thomas! I am glad that I am on the right track. Do you happen to have a reference for the guideline that you are referring to.

I have made everyone involved aware including the provider and management. It would be a detriment to just let this type of thing go.
The guideline Thomas is referencing to is from the CMS E/M guidelines:

"Notes on the Documentation of History:
-You may list the CC, ROS, and PFSH as separate elements of history or you may include them in the description of the HPI.

-You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. You may document the review and update by:

• Describing any new ROS and/or PFSH information or noting there is no change in the information
• Noting the date and location of the earlier ROS and/or PFSH

-Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information.

-If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history."


I don't see any references to HPI as well, and the HPI is more or less sacred to the performing provider. The new guidelines for 2019 do suggest that ancillary staff can write and in essence act like a scribe for the History section, as long as the provider fully attests to it. More details found in the link above.


Hope this helps answering your question!
 

DavitaPhillips03

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Thank you for your feed back Thomas! I am glad that I am on the right track. Do you happen to have a reference for the guideline that you are referring to.

I have made everyone involved aware including the provider and management. It would be a detriment to just let this type of thing go.
 
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