Orthopedic Coding Alert

Question: My coworker thinks an orthopedic surgeon must take a patient's history. But I think a nurse can perform this duty. Who is right?

Tennessee 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 orthopedic surgeon or nurse practitioner (NP), 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.

The documentation should include a notation supplementing or confirming the information that others recorded.
The physician should sign the chart to document incident-to services, such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), as well as for higher-level E/M services (for example, 99212-99215).

- You Be the Coder and Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J.