Wiki HPI not in 1st person

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irma011

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If a doctor's scribe is documenting the HPI & documents it in 3rd person, does this make this encounter nonbillable? Would the HPI become invalid? example of what is documented is "patient states she is here today to get established with Mrs. Smith"
 
Has someone told you this is a problem?

This is not a problem. Third person, first person, any form of voice does not make an encounter nonbillable or invalid.
 
SharonCollachi said:
Has someone told you this is a problem?

This is not a problem. Third person, first person, any form of voice does not make an encounter nonbillable or invalid.
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There is actually an article from AAPC https://www.aapc.com/blog/23875-8-tips-for-compliant-history-component-documentation/ that states the HPI must be done by the provider. Since the HPI is the physician's responsibility, it would only be appropriate that the HPI be documented in 1st person & not 3rd? When they have a scribe, the HPI should have been verified by the provider & if had been done so, then the pronoun should have been removed. In this case it wasn't, so my questions is does this make the encounter billable or nonbillable?
 
The article says: Every encounter must have a minimum of one HPI or the status of at least one chronic illness. The provider must describe the problem (how bad it is, how long it has been going on, etc.).
HPI may be documented by the performing provider ONLY. Copying the nurse’s notes does not count.

I'm not seeing where the statement "patient states she is..." negates that. The provider is documenting what the patient said.
 
SharonCollachi said:
The article says: Every encounter must have a minimum of one HPI or the status of at least one chronic illness. The provider must describe the problem (how bad it is, how long it has been going on, etc.).
HPI may be documented by the performing provider ONLY. Copying the nurse’s notes does not count.

I'm not seeing where the statement "patient states she is..." negates that. The provider is documenting what the patient said.
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That's not the part i'm indicating makes the HPI invalid. I'm talking about the part of "Mrs. Smith" being mentioned in the HPI even though Mrs. Smith is the provider who is supposed to be documenting the HPI. So instead of it stating "patient here to establish care with Mrs. Smith" it would be more appropriate to say "patient here to see me today to establish care" does that make sense?
 
irma011 said:
That's not the part i'm indicating makes the HPI invalid. I'm talking about the part of "Mrs. Smith" being mentioned in the HPI even though Mrs. Smith is the provider who is supposed to be documenting the HPI. So instead of it stating "patient here to establish care with Mrs. Smith" it would be more appropriate to say "patient here to see me today to establish care" does that make sense?
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I agree that the scribe should have changed that, but I still don't think it invalidates the visit.
 
My question is: Is the patient being evaluated for a medical condition? Or is the patient there simply to "Establish' care? If no medical condition is being addressed there would be no medical necessity.
 
Orthocoderpgu said:
My question is: Is the patient being evaluated for a medical condition? Or is the patient there simply to "Establish' care? If no medical condition is being addressed there would be no medical necessity.
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Patient was seen to establish care and had a complaint, however, i do see some charts where the patient is just there to establish care & don't have any complaints..
 
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