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Documentation of Chief Complaint

  1. #21
    North Carolina
    Medical Coding Books
    Quote Originally Posted by coder911 View Post
    Thank you so much for listing these source documents. I have been on the hunt for something substantial enough that I could deliver to our EMR vendor and multiple providers.
    This is an industry standard that has been hard to "prove" to other entities due to the "lack" of specificity in the 1995/97 guidelines. Apparently it allows some individuals enough room to argue that because it does not specifically state "ancillary staff can't document the HPI" - means that they can defend that position in court.
    I believe this issue needs direct attention - exponentially so now with EMR becoming so relevant.
    Thank you again, cheers!
    Happy to help~

    Update to date Palmetto link...||
    Last edited by RebeccaWoodward*; 09-14-2011 at 10:09 AM.

  2. #22
    Quote Originally Posted by RebeccaWoodward* View Post

    Typically, I see "eye to eye" with you but not in this case. CMS has made it clear, or so to me, that ancillary staff cannot document the CC. There are many other articles and well known coding guru's that agree with this ideology. I don't know about your carrier but my local carrier always emphasizes this requirement at our conferences.

    DG-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.

    AAOS--- "The chief complaint (CC) and history of present illness (HPI), however, are different from the rest of the components in the patient history. Reporting and documenting the CC and HPI must be done by the physician or NPP reporting the service."

    I'm not suggesting that ancillary staff can't write down the reason for the visit but it's very clear that the physician must acknowledge/add/sign...something in addition to this comment.

    "To agree or not to agree" least we can still have a healthy discussion whether we agree on the subject or not.

    I agree with you on this 100%. We've also had this discussion. Our MA's/ Nurses do document the " reason for visit" and the provider documents the CC and does the HPI section.

    It surprises me ( at times ) how a patient will tell the MA/nurse the reason for the visit and it differs from what they actually tell the provider! I've seen it plenty of times where the MA will go in and ask the patient why they are here/problem and they tell the dr the "real reason" why they are here, not sure if they maybe embarrassed or what but I just thought I'd add my 2 cents on this one.

    With CMS stating what the MA or ancillary staff can document tells me that whatever isn't listed there can't be documented by the ancillary staff/MA. IF it were it would be stated ( just my opinion).
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

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