Shift in Intake

October 1, 2007

I recently read that CMS will soon adopt rule changes regarding the new patient intake history/interview process. I thought I read that physicians have to take the entire history themselves and can no longer rely on what a medical assistant or other ancillary staff member writes down. Can you help? Have you heard of this?

Question: I recently read that CMS will soon adopt rule changes regarding the new patient intake history/interview process. I thought I read that physicians have to take the entire history themselves and can no longer rely on what a medical assistant or other ancillary staff member writes down. Can you help? Have you heard of this?

Answer: Physicians Practice covered this in our e-mail newsletter, “Pearls on Coding.” (To sign up, visit our E-Newsletter Signup Page.) In the newsletter, coding expert Bill Dacey writes:

CMS has given more substance to the documentation requirements for the history of present illness (HPI) portion of a physician’s E&M history. This latest addition to a long line of CMS “clarifications” is neither welcome nor practical in the provider community.

Coming in the form of a much-copied e-mail, the guidance says that a physician or nonphysician practitioner must write the HPI, not just sign an HPI that has been taken in part or entirely by ancillary staff.

Anyone who has worked in a practice for any measurable time knows that whether a nurse or a provider actually records the HPI, the substance of it - the actual medical information being communicated - is clearly used by the provider and is, in reality, part of the provider’s work. If physicians didn’t check the HPI data, and the review of systems for that matter, they wouldn’t know what to examine and how to arrive at their decision - the assessment and plan portion of the note. The HPI is integral to the encounter.

It is absurd to imply that because an element of the work isn’t written by the provider then it isn’t part of the “physician work.”

In the past two years, the majority of “guidance” that CMS has given in relation to E&M has consisted of leaked memos, comments, and unattributed statements. It’s time for CMS to issue formal direction.