ED Coding and Reimbursement Alert

Question: Can the history of present illness (HPI) elements be obtained from the nurse's assessment note? The physician does not sign off on this document. I'm only coding the physician component of the ED visit. I was under the impression that if the physician reviewed and agreed with the nurse's notes (and documented her review), then the HPI elements could be used.

North Carolina Subscriber

Answer: The HPI elements cannot come from the nurse's notes. Most experts agree that because CMS hasn't explicitly stated that someone other than the physician can do the HPI, this means that a physician is the only one who should perform it. The current interpretation is that a physician must perform/obtain not only the HPI but PE as well. Anyone can obtain the patient's past, family, social history (PFSH), and review of symptoms (ROS), but the physician still needs to sign off that these elements have been reviewed in order to get credit.

For those in teaching-physician settings, take note: Teaching-physician rules say you can count the HPI that residents perform IF the attending physician clearly documents his independent confirmation of the key elements of the history, physical exam and medical decision-making. The resident can gather the HPI info, but the attending must document his review and agreement with the essential parts of the history.

Reader Questions and You Be the Coder were reviewed by David McKenzie, reimbursement department director, American College of Emergency Physicians in Irving, Texas; and Michael Granovsky, MD, CPC, CFO, of Greater Washington Emergency Physicians in suburban Maryland.