ED Coding and Reimbursement Alert

Question: I am confused about whether the information that nurses gather during triage can be used in the documentation of the history of present illness (HPI) portion of the patient's history. This is generally recorded on our preprinted forms, which are then given to the physician. But I've also been told that the doctor must personally do the HPI. Which is correct?

Wisconsin Subscriber

Answer: Under Medicare guidelines, the physician must personally conduct the HPI in order to have that information factored into the E/M service level assigned for the ED visit (99281-99285). However, the physician is allowed to reference other sources for further components of the history like the review of systems (ROS) and past family and social history (PFSH). These may include notes from triage or nursing staff, history conducted by other physicians, and information provided directly by the patient on an admission form.
 
These requirements are found in both the 1995 and 1997 Medicare evaluation and management documentation guidelines (DGs). These rules were established to help a physician meet documentation requirements without having to repeat each piece of information that had previously been gathered. The 1995 DGs explicitly state, however, that the ED physician must make clear reference to where the previously collected information is found in the patient's medical record, even if that notation merely records that nothing was found. For example, the ED physician might document that he had reviewed the previous history and that "nothing notable was identified."