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HPI documentation requirements

aalsabrook

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Anybody know of any language that states that the HPI has to be documented by the physician personally? Or can he just review it? We have audit information that states that the record indicates that ancillary staff took the info and therefore it was downcoded.
 

btadlock1

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Anybody know of any language that states that the HPI has to be documented by the physician personally? Or can he just review it? We have audit information that states that the record indicates that ancillary staff took the info and therefore it was downcoded.
Not in so many words...documentation guidelines state:
"The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient.
To document that the physician reviewed the information, there must be a notation
supplementing or confirming the information recorded by others."
The fact that only the ROS and PFSH are mentioned, implies that it would not be acceptable for the CC or HPI to be documented by anyone, other than the physician. Most MAC's have supplemental guidance that spells it out, though. The auditor was correct.
 

btadlock1

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You may find these links helpful:
http://www.aafp.org/fpm/2010/0300/p22.html

http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml

"Q 18. Who can perform the History of Present Illness (HPI) portion of the patient's history?
A 18. The history portion refers to the subjective information obtained by the physician or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the HPI. Only the physician can perform the HPI.

Q 19. If the nurse takes the HPI, can the physician then state, "HPI as above by the nurse" or just "HPI as above in the documentation"?
A 19. No. The physician billing the service must document the HPI.

Q 20. Can the History of Present Illness (HPI) elements be counted for both the Chief Complaint (CC) and the associated signs/symptoms? For instance, a patient presents with chest (location) pain (CC) that she has had for 3 days (duration). She also experiences shortness of breath (associated signs/symptoms) when walking up the stairs (context).
A 20. Yes. According to the E/M 1995 and 1997 DG, "The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness."

;)
 

aalsabrook

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Yes! That helps tremendously! I really just need some other people to agree with me! We have one of the references you used but the physician I am working with states that it isn't enough to say that it is implied that the phys must collect the HPI so the other references will help.

thanks!
Anne
 
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