Ob-Gyn Coding Alert

Question: Are nurses in a doctor’s office allowed to do the HPI, ROS and Assessments as long as the doctors’ signs the note agreeing with the information? I have reviewed info on CMS website, and they recommend that at the bottom of the note that a note should be made by the doctor saying they reviewed the information and agreed/disagreed or changed the information. So does that mean they can?

Virginia Subscriber

Answer: No. The guidelines set the tone for who does what. The RN can take a history (ROS, PFSH and can even document the chief complaint) but only the billing provider can document the HPI. The guidelines do make this clear. The assessment is also the responsibility of the billing provider, not the RN. 

If you are billing incident-to for the entire visit, the RN could be paid as a 99211 (Office or other outpatient visit for the evaluation and management of an established patient …). This level of service does not require an HPI or an assessment that is more than a simple conclusion that anyone with very little medical training could make. 

The physician “notation” would apply to a medical resident having done the HPI and assessment — not an RN or it would apply to the rules surrounding doing an ROS or PFSH. Here are the exact rules, and notice that HPI is not among the listed elements that can be done by someone other than the billing provider:

“DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.

DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting there has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH.

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.”