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Pamela Posted Wed 17th of January, 2018 11:19:37 AM
Who can record the Chief Complaint? I think it is only the provider. I have an EHR that is trying to say the Ancillary staff can record the CC and HPI as long as the physician states he reviewed it. I was able to convince them the HPI is the work of the physician, but they are arguing about the chief complaint. Can you help me? My MAC, FCSO, does not give guidance on this question. They refer back to CMS E & M documentation guidelines.
SuperCoder Answered Thu 18th of January, 2018 00:56:51 AM


Chief complaint (CC) is considered part of HPI and cannot be reported by ancillary staff only.  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 by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and write a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name. Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI).


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