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Who Can Document the Chief Complain

  1. #11
    Stuart Sailfish Chapter
    Medical Coding Books
    What about providers that are using EHR. and have Ancillary Staff scribing for the physicians in the room?????
    Candice Fenildo, CPC, CPMA, CPC-I, CPB, CENTC, CRHC, AAPC Fellow
    Director of Operations
    Ear, Nose and Throat Associates of South Florida, PA

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  2. #12
    Duluth, Minnesota
    hi, just thought I'd share this info: From Progressive Healthcare Conference 07/23/08 - perh CMS E/M guidelines:
    ancillary staff may document ROS and PFSH
    PROVIDER must personally document HPI
    Chief Complaint may be inferred

    I think I said that in one of the earlier posts - basically HPI/CC same
    Confirmed at this meeting and on the CMS website...
    Donna, CPC, CPC-H

  3. #13
    Sherry, The answer is the Documentation guidelines you are referring to...Only the ROS and PFSH can be documented by ancillary personnel, because that is stated as allowed. Obviously, they do not say that about HPI, Exam or MDM. Documentation guidelines also allow you to have the CC "inferred" from the HPI. So, while an ancillary person can document in the part of the medical record that is the CC, if you do not have anything out of the HPI to "infer" a CC, you do not have one. (In that case you would not have much of an HPI either.) The only other resource you may want to look at would be the CPT Assistant Archives, back from when the DG were first published April of 95 or 96...They publish the reasoning behind these codes. Something I have not been able to get ahold of myself, but I really want to read those. Hope this helps.
    Kelly G.

  4. #14
    North Carolina
    Last Q/A addresses this question~
    Rebecca CPC, CPMA, CEMC

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