HISTORY OF PRESENT ILLNESS
Published on: 8/24/2007
Two Medicare carriers, Palmetto GBA and Noridian, recently published information regarding who may perform the HPI. (WPS published similar information in 2006.) Noridian writes: “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 and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it.” Palmetto GBA cites CMS as the authority for its position that, “Only the physician who is conducting the E/M visit can perform the HPI.”
A scribe may record the HPI dictated by the physician. Noridian also writes: “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.”
Furthermore, Part B News published in their June 11, 2007 issue that they received confirmation from CMS that information published by Noridian is correct. Corcoran Consulting Group is aware of at least one carrier request for documentation of the “Physician’s HPI” in a recent chart review.