Internal Medicine Coding Alert

Question: Is the physician the only person who can take a patient history, or can a nurse complete it?

Kansas Subscriber

Answer: Any employee who has been adequately trained can help document a patient's history.

Support: E/M service documentation guidelines state that ancillary staff can record the review of systems (ROS) and/or the past, family, and social history (PFSH) portions of the visit. Only the physician or other qualified health care professional (such as a nurse practitioner), however, may complete the history of present illness (HPI).

Remember: If another staff member takes the history, the physician must sign off on the patient's chart and indicate that he reviewed the history notes. He should include a note supplementing or confirming the information recorded. Also verify that 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 ...), or any higher-level E/M services (such as 99212-99215).