The article “A New Approach to Making Your Doctor-Nurse Team More Productive,” by Peter Anderson, MD, and Marc D. Halley, MBA [July/August 2008], contains advice that appears to conflict with Medicare's Documentation Guidelines for Evaluation and Management Services. The article suggests delegating services usually considered to be physician activities, including the history of present illness (HPI).
According to our Medicare carrier, Noridian Administrative Services, “The Centers for Medicare and Medicaid Services has clarified that only the physician or non-physician practitioner who is conducting the evaluation and management visit can perform the HPI and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff. … 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). An example of unacceptable HPI documentation would be ‘I have reviewed the HPI and agree with above.’” (The above statement can be found on the Noridian web site at http://bit.ly/aKDnvk.)
Dr. Anderson adheres to our Medicare carrier's rules (TrailBlazer Health Enterprises) and Medicare's E/M documentation guidelines. In the model presented in his article, the HPI is not delegated to a non-physician staff member. The medical assistant welcomes the patient and begins asking health- and symptom-related questions based on a physician-developed protocol related to the reason for the visit. This preliminary information is recorded in the patient record. As you noted, the nonphysician can question the patient and this information can be used as preliminary information, according to Medicare.
When Dr. Anderson begins the patient visit, the non-physician staff member verbally communicates the preliminary information to Dr. Anderson in front of the patient and then becomes the scribe for the remainder of the visit. At this point, Dr. Anderson validates or updates the preliminary information, further interviews the patient and personally completes the HPI information. He also queries the patient on the status of any chronic conditions and addresses health prevention screening. While the non-physician staff member is contributing to a portion of the HPI, it is always supplemented and completed by Dr. Anderson. It is this information that is used for his code selection and plan of care.
As indicated in the article, Dr. Anderson is the owner of the HPI due to clarification of the preliminary information and the gathering of additional information through patient interview.