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HPI documentation question

  1. Default HPI documentation question
    Medical Coding Books
    When the nurse puts the patient in to the exam room for the doctor she will ask questions relating to the illness or the injury and write in the chart. My question is if the doctor writes that he reviewed and agrees can he count this as HPI? I am auditing a doctors notes and the nurse wrote a detailed history and the doctor wrote that he agrees with what was written rather than rewriting everything.

    Thanks for any help.

    Denise Smith CPC-A, CEMC

  2. #2
    Daytona Beach, FL
    I was told that the doc must document this in his own writing and words. We have the same situation at our practice and our docs were just checking a box staying he reviewed and confirms the above note, which the nurse documented and apparently this is not allowed. Our MAC states the doctor must collect the HPI, not the ancillary staff, only the ROS and PFSH can be done by other staff or patient our docs are now being retrained!

    Other thoughts on this would be interesting!

    Jodi Dibble, CPC

  3. #3
    North Carolina
    I agree Jodi. I did present this question to our Medicare medical director and he basically stated the same. He did acknowledge that it is customary for ancillary staff to record the reason for the visit however it is ultimatley the providers responsibility to record the HPI.

  4. #4
    Minneapolis MN
    This is from WPS Medicare and this is what we follow:

    Q 21. 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 21. No. The physician billing the service must document the HPI.

  5. #5
    Default Hpi
    CMS is clear that the physician must document the HPI, my physicians and providers protest the rewriting as well; but I tell them they must regurgitate the information. They are likely covering the HPI with the patient anyway.

    The good thing about providers and physicians are that they are trainable! They want to be paid as much as we want them to be

    Susan R, CPC, CPMA, CEMC

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