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I am trying to find where it states that the physician must be the one to document the HPI in order for it to count in the E/M level. Our nurses will take a brief history when putting the patient in the room. The doctors will review what the nurses wrote and then add to it. However, some of the doctors do not add to it counting what the nurse wrote as the history. I have a meeting this afternoon and I am trying to find this to back up what I have been telling the doctors.

Thanks for any help.

Denise Smith CPC-A, CEMC


True Blue
North Carolina
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If you do a search in the search engine, you will find lots of info on this subject. However...

The HPI must be recorded by the MD/NPP. The '97 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. (This automatically excludes the HPI)

-Couple of sites-

Palmetto: What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an Evaluation and Management encounter? Can ancillary staff act as a scribe for a provider?

Ancillary staff may only document:

Review of Systems (ROS)
Past, Family and Social History (PFSH)
Vital Signs

These three areas must be reviewed by the physician or NPP who must write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can PERFORM the History of Present Illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances an Office or Emergency Room triage nurse may document pertinent information regarding the Chief Complaint/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

WPS: The HPI may only be obtained by the provider, and may not be obtained by ancillary staff.

Cigna Government (my carrier)-I have emailed the medical director and he emphasized that the provider/npp MUST document the HPI...this can not be delegated to ancillary staff.


Local Chapter Officer
Kansas City, MO
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I recently heard via a teleconference "the guidelines do not specifically say that the nurse can't document the HPI".
But, I think that is majorly stretching it (what's next...them saying the DG's do not specifically exclude the nurses documenting the exam?!), and I am sticking with Rebecca's line that the DG's "automatically exclude" it.
Provider should be documenting the HPI!! =)