ED Coding and Reimbursement Alert

Question: I would like some written information about the documentation of the history of present illness (HPI) portion of the patients medical history on pre-printed forms. It is my understanding the review of systems (ROS) and the past, family, social history (PFSH) can be documented by nursing/ancillary staff for the physician and that this documentation will stand with HCFA as long as the physicians signature is on the form stating that he has reviewed the nursing assessment.

It is also my understanding that the ER physician must complete his own HPI. The HPI is essentially the same information that the ED nurse is expected to get during triage of a patient when he or she presents in the ED seeking medical care.

Is it permissible to include the nursing assessment as the HPI and make any documented changes necessary by the doctor as he reviews this information with the patient, or must he also complete this information with his updated notations? The system we are using for documentation purposes is aligned with the 1995 Medicare guidelines. Based on proposed changes, it seems this is likely to be reviewed further in the new physician documentation rules. We are interested in obtaining some clear information prior to that. We are using [a template system] to address our daily documentation requirements for the ER physicians examination and treatment plans.

Anonymous Illinois Subscriber

Answer: Your physicians may refer to portions of the history from any number of sources (nurses notes, history from other doctors, patient-generated information), advises Susan Callaway Stradley, CPC, an independent coding consultant and educator based in North Augusta, S.C. However, you are correct in noting that the physician must take the HPI.

According to the 1995 version of the evaluation and management (E/M) documentation guidelines, there must be a reference to where the previously recorded history information is located in the patients medical record, and what pertinent information was found. For example, reviewed history taken by ED physician Smith earlier today, notably patient has been having seizures for three years, no family history of seizures, or reviewed history taken during triage, nothing notable found. The most important thing to remember is that the reference must have some indication of what was found, even if the statement is that nothing was found.

If this statement is present, the doctor can be given credit for the ROS and PFSH documented by the other source in addition to his own documentation. This mechanism was specifically designed to aid physicians in meeting the guideline requirements without reiterating every bit of information already taken by other sources. This requirement is listed in the 1995 and 1997 E/M guidelines, and those may be downloaded off the HCFA Web site, www.hcfa.gov. When searching on the Web site, click first on the Medicare button, choose Professional/Technical Information, then scroll down until you see the heading Documentation Guidelines.

According to the 1995 documentation guidelines, a ROS or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence the physician reviewed and updated the previous information. This may occur when a physician reviews and updates his own record, or in institutional settings or group practices, where physicians may use a common record. The review and update may be documented by describing any new ROS or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and PFSH.