General Surgery Coding Alert

Question: Must the surgeon take a patient's history, or can a nurse or other nonphysician staff take the history prior to the surgeon meeting the patient?


California Subscriber


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 (for instance, 99212-99215).