Results 1 to 4 of 4

CMS Regulations for HPI

  1. Post CMS Regulations for HPI
    Medical Coding Books
    Can anyone point me in the direction of where I will find rules/regulations pertaining to who may document the HPI in a patient record? My understanding is that CMS states only the physician may do so yet we are unable to locate this regulation in text.

  2. #2
    Default Help
    Physicians who allow unqualified ancillary staff do the HPI are subjecting themselves to the risk of a major compensable event and a failure of care standards at best. However, the answer to your questions is state specific. Some states state that a physician may have ancillary staff document the HPI but must review for accuracy and sign off on it in order to factor it in E/M Coding. Other states have taken a firmer position and rejected the idea totally. Please find an exerpt from Medicare:

    Medicare B News Issue 238 July 10 2007

    Heading: Clarification
    Title: Evaluation and Management Clarification

    The Centers for Medicare and Medicaid Services (CMS) has clarified that only the physician or non-physician practitioner (NPP) who is conducting the evaluation and management (E&M) visit can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff.

    Noridian Administrative Services (NAS) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when "physician" criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name.

    Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be "I have reviewed the HPI and agree with above."

    Applies to the states of: AK, AZ, CO, HI, IA, MT, ND, NV, OR, SD, UT, WA & WY.

    Posted on: 7/10/2007


    I hope this helps!


  3. #3
    Greeley, Colorado
    Anyone have any links that I can use for this subject to present to a pediatrician who routinely has his nurse document the HPI?

  4. #4
    The CMS website has both the '95 and '97 documentation guidelines. Here is the link:
    Page 5, specifically states what ancillary staff may document, and the HPI is not one of them.

    Good luck!
    Evangelina Frohna, CPC, CEMC

Similar Threads

  1. Federal regulations?
    By Lynda Wetter in forum Auditing General Discussion
    Replies: 6
    Last Post: 06-17-2014, 05:13 AM
  2. Billing Regulations for a PA
    By csamps/CPC in forum Billing/Reimbursement
    Replies: 2
    Last Post: 05-28-2010, 11:16 AM
  3. Coding regulations
    By tham12005 in forum Medicare Regulations
    Replies: 5
    Last Post: 12-28-2009, 04:04 PM
  4. Hmo regulations
    By EMACHORRO in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 08-27-2009, 01:01 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.