decisionhealth Newsletters, Part B News - 2007 Issue 6 (June)
CMS: HPI is physician work, with no exceptions
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Article Overview
This article reviews CMS and Medicare contractor guidance about the History of Present Illness and who may document it for audit purposes. It is aimed at physicians, non-physician practitioners, coders, and compliance staff who need to understand documentation expectations and the role of ancillary staff, as well as how contractor guidance is being interpreted by CMS. The article focuses on policy clarification, audit risk, and the difference between Medicare and private payer expectations.
Why This Topic Matters
Documentation of the History of Present Illness affects evaluation and management compliance and audit exposure. Understanding CMS guidance helps practices reduce denials, avoid improper documentation habits, and align physician workflow with Medicare rules.
What You Will Learn
- How CMS and Medicare contractors have addressed History of Present Illness documentation
- Which types of documentation involvement by ancillary staff are described as problematic
- Why Medicare documentation expectations may differ from those of private payers
- How contractor guidance and CMS confirmation affect compliance concerns
Who Should Read This
- Physicians
- Non-physician practitioners
- Medical coders
- Compliance staff
- Practice managers
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