Question: Must the physician take a patient's history, or can a nurse or other nonphysician staff take the history prior to the physician meeting the patient? Clinical and coding expertise for You Be the Coder and Reader Questions provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.
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Answer: Any employee can take the history. In fact, the E/M service documentation guidelines state that ancillary staff may record the review of systems (ROS) and/or past family social history (PFSH). Although nurses often record this information, a front-desk staff member may even perform the function. The surgeon or nurse practitioner, however, must complete the history of present illness (HPI).
Be careful: The physician must sign off on the patient's chart and must indicate that he reviewed the history notes. Documentation should include a notation supplementing or confirming the information that others recorded.
Make sure the physician signs off on any incident-to services, such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), as well as higher-level E/M services.