DecisionHealth, DecisionHealth - 2012 Issue 6 (June)

Template abuses: Allowing staff, not the physician, to complete HPI

The problem: Ancillary staff, such as nurses and medical assistants, document elements of the history of present illness (HPI). E/M Documentation Guidelines state that ancillary staff can document the review of systems and past, family and social history but are silent about whether those staff members can record the HPI. That means billing providers – physicians or non-physician practitioners who are the billing providers or are rendering incident-to services – must document the HPI.

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