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Who Can Document the Chief Complain

  1. #1
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    Default Who Can Document the Chief Complain
    Medical Coding Books
    I have been to several conference's lately that have indicated that only the Doctor/Proivder of services can document the chief complaint. I have brought this back to my peers and they want proof. The only proof I have is the 1995 documentation guidelines that indicate that ancillay staff can document the ROS and PFSH. They say that is subjective and they want something from an accredited organization, CMS, AAPC, Ect to back up that statement. Can I get some help.

  2. #2
    Location
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    The 6/11/07 issue of Part B News addresses this issue. It also references the Noridian Medicare web site regarding their requirements.

  3. #3
    Location
    Duluth, Minnesota
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    lol.. I've tried to comment on this issue a few times and keep deleting my post - I just sit here and shake my head, I don't get it. I don't get why it's an issue... I just can't understand it..
    Donna, CPC, CPC-H

  4. #4
    Location
    Southern IL Carbondale
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    Default
    It is an issue for me because I audit the provider charts and I need to know for auditing purposes.

  5. #5
    Location
    Greeley, Colorado
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    The chief complaint (i.e. "ear pain") may be noted by the ancillary staff, but the actual HPI must be documented by the provider.

  6. #6
    Location
    Duluth, Minnesota
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    yes, sgann - I know it's an issue for you...and others too - but I don't understand why it is. (it's nothing against you or your question) I just don't understand why it's a problem - doesn't the physician document/dictate the full care provided? it's not like we carve anything out and give credit/charges to the person who does the CC - or ROS or whatever - I think because I haven't come across this issue with my providers, I don't understand why it would be an issue at all..? - LOL this is why I kept deleting my other posts! "I" can't explain myself!
    Donna, CPC, CPC-H

  7. #7
    Location
    Southern IL Carbondale
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    9
    Default Lisa
    Can you please give me the back up documentation to your statement. I need this in writing from CMS, AAPC, AHIMA or an organization. My peers will not accept responses from a forum or list serve. On the intelicode forum Jan Rasmussen CPC auditor states the ancillary staff can document the CC but that the provider has to restate it in the HPI. This idea is coming from the 1995 and 1997 CMS guidelines that states ancillary staff can do the ROS and PFSH which implies that is all they can do. The DG in the guidelines states that the CC HPI and ROS can be all in one or seperate. That is why they are stating that the CC has to be restated in the HPI by the provider to count.

    I don't know, I have been doing this for at least 2 years and this is the first time I have ever heard this.

  8. #8
    Location
    Greeley, Colorado
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    Quote Originally Posted by sgann View Post
    Can you please give me the back up documentation to your statement. I need this in writing from CMS, AAPC, AHIMA or an organization. My peers will not accept responses from a forum or list serve. On the intelicode forum Jan Rasmussen CPC auditor states the ancillary staff can document the CC but that the provider has to restate it in the HPI. This idea is coming from the 1995 and 1997 CMS guidelines that states ancillary staff can do the ROS and PFSH which implies that is all they can do. The DG in the guidelines states that the CC HPI and ROS can be all in one or seperate. That is why they are stating that the CC has to be restated in the HPI by the provider to count.

    I don't know, I have been doing this for at least 2 years and this is the first time I have ever heard this.
    Try this link to Noridian/CMS:
    https://www.noridianmedicare.com/sha...ification_.htm

    Is that helpful? I can't give you the link for Part B News, you have to be a subscriber. But the PBN article is based on this statement by Noridian.
    Lisa

  9. #9
    Location
    Duluth, Minnesota
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    http://www.wpsmedicare.com/part_b/pu..._history.shtml
    on this link as well it states:

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

    The CC/HPI are basically one in the same - so why would anyone separate to a point where an ancillary staff documents the CC but the provider does the HPI? The CC rolls right into the HPI - It's "one" of the "three" sub- components under the HISTORY COMPONENTS. CC/HPI & ROS & PFSH.
    Donna, CPC, CPC-H

  10. #10
    Location
    Milwaukee WI
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    4,466
    Default Go back to your source
    Sherry,
    You indicate that you've been to several conferences lately where this was brought up. Perhaps one of those conference speakers/leaders has the proof your peers are requesting?

    Good luck,
    F Tessa Bartels, CPC, CPC-E/M

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