ED Coding and Reimbursement Alert

Question: If a nurse documents an HPI in her notes and the ED physician documents that he read the notes and agrees, can we count this as the physician's HPI? Or must the physician perform the HPI himself?


Idaho Subscriber

Answer: According to Medicare's 1995 Documentation Guidelines, the physician must personally perform the history of present illness (HPI). The guidelines state that ancillary staff can perform other evaluation and management history components, such as the review of systems (ROS) and past family social history (PFSH), but HPI is not listed among them.

Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems Inc., an ED coding and billing company in Stoneham, Mass.