HPI — My Doctors Don’t Document This, the MA Does. Is This OK?

image_print

Question:

Since we implemented our EHR, the MA completes the first part of the history, which includes the history of present illness (HPI). I assume the doctor reviews it but he does not typically document any additional HPI. Is this a problem with E & M documentation?

Answer:

Great question! This has become a fairly common occurrence, especially since the growth of EHR use by practices. And yes, it is an issue. According to E & M guidelines, the physician (or NP, PA, CNS, if they are the provider performing the service) must personally document the chief complaint and the HPI. If this information is already in the record, entered by an MA for example, the physician must personally elicit and document the reason for the visit and pertinent HPI elements in order for the service to meet minimum E & M guidelines. Without this information documented by the physician, a new visit or consultation would not be reportable.

KZA Featured Products  

  • Save time and eliminate errors when you code with Orthopaedic Code-X. It combines all the information and functions you need to code with complete confidence.
    Webinars
    Save time and eliminate errors when you code with Orthopaedic Code-X. It combines all the information and functions you need to code with complete confidence.
    Code-X
    Don't spend hours writing policies when you can customize this comprehensive manual to meet your unique practice policies and needs.
  • Don't spend hours writing policies when you can customize this comprehensive manual to meet your unique practice policies and needs.
    Employee Manual on CD
    KZA’s E&M Profile Analyzer* compares E&M coding patterns against your specialty’s state and national figures using CMS’ most recently published claims database.
    E&M Profile Analyzer
    Now you can create job descriptions in no time flat! This comprehensive set of job description samples includes a title and job summary, suggested education, skills, and other qualifications, and a list of detailed duties. Language that supports the Americans with Disabilities Act is also included. Open each sample description and customize it to your needs.
  • Don't spend hours writing policies when you can customize this comprehensive manual to meet your unique practice policies and needs.
    Don't spend hours writing policies when you can customize this comprehensive manual to meet your unique practice policies and needs.
    Background Checks
    Don't spend hours writing policies when you can customize this comprehensive manual to meet your unique practice policies and needs.
    Select™
  • Don't spend hours writing policies when you can customize this comprehensive manual to meet your unique practice policies and needs.
    Proception™
    Don't spend hours writing policies when you can customize this comprehensive manual to meet your unique practice policies and needs.
    Don't spend hours writing policies when you can customize this comprehensive manual to meet your unique practice policies and needs.