Reader Questions:
All Staff Members Can Perform History Element
Published on Fri Jul 01, 2005
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.
