Otolaryngology Coding Alert

Your ENT isn't wasting his time confirming a patient's history of present illness (HPI). Turns out it's his duty.

You-re not alone if you-ve read and re-read the E/M documentation guidelines looking for the definitive answer to who can perform the HPI. Many practices allow a nurse to take the past, family and/or social history (PFSH) and review of systems (ROS), or allow a patient to complete a form detailing this information. The physician then obtains the HPI.

If your practice wants to verify whether this is a proper use of everyone's time, you might be hard-pressed to find the guideline in writing. Here's where to turn and the requirements staff need to stick to.

You may permit a staff member or even allow the patient to record the PFSH and ROS elements. This guidance stems from the AMA- and CMS-approved E/M guidelines. "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient," according to the 1995 and 1997 documentation guidelines for E/M services.

Don't miss: The physician must document that he reviewed the PFSH and ROS history elements. The notation must supplement or confirm the information that others recorded, the guidelines stipulate.

For instance, if an ENT reviews a patient-completed PFSH and ROS form, he could indicate his review "with a brief line, such as -I reviewed the history form filled out by the patient on Sept. 4, 2007,-" says Margaret M. Maley BSN, MS. He should also sign and date the form and retain it in the patient's medical record.

Because the E/M guidelines create concrete PFSH and ROS recording criteria, many people look to the same place for HPI reporting information. "The guidelines have never defined if the staff was allowed to document the history of present illness," says Teresa Thompson, CPC, CMSCS, CCC, a consultant in Carlsborg, Wash.

Some Medicare carriers closed the door on any confusion in this area. A CMS carrier clarified that only the physician or nonphysician practitioner (NPP) who is conducting the E/M visit can perform the HPI and chief complaint (CC), according to Noridian's E/M clarification that appeared in Medicare B News Issue 238, July 10, 2007: "This is physician work and shall not be relegated to ancillary staff."

Get this: You should always adhere to this guidance. "Although only some carriers published the policy, it is Medicare's national policy," says Mary Pat Johnson, COMT, CPC, COE, senior consultant for Corcoran Consulting Group.

Why: Medicare bases its rationale on the fee schedule, Johnson says. The E/M service code values include physician work for performing the HPI.

Catch this: The absence of any HPI performer statement indicates ancillary staff does not have permission to collect the HPI. CMS specifically states that ancillary staff can collect ROS and PFSH. If CMS had extended HPI permission to staff, the guidelines would have included this allowance.

The policy, however, allows for some staff involvement in the HPI. Ancillary staff, such as a nurse, can gather preliminary information by questioning the patient regarding the CC, but the physician must confirm this information, Noridian's policy says.

Scribe allowed: The nurse may record the HPI as the ENT dictates and performs it. In this case, the physician must review the information as documented, recorded or scribed and write a notation that he reviewed it for accuracy, did perform it, adding to it if necessary and signing his name, according to Noridian's Part B News.

Carriers have requested information that supports the physician's HPI performance, including asking patients and/or staff to verify the doctor's role. To support services on post-payment review, the physician must document his involvement in obtaining the HPI, Thompson says.

Depending on your documentation system, follow these Thompson-recommended best practices:

Written: The difference in handwriting as well as notes from the physician expanding on the information obtained from the patient can support the physician's role.

Paper templates with boxes: The physician must obtain the information from the patient, which he indicates by checking a box.

Electronic medical records (EMR): Your ENT could indicate in the note that he participated in obtaining the information. Your practice might want to implement a clinic protocol indicating that the physician is responsible for obtaining the HPI information and that ancillary staff may or may not document the information obtained, depending on the physician.

Want to get the exact documents? Go online for Noridian's resources:

- www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EEZAZlkyFyxzeFsPmT&tmpl=part_b_viewnews&style=part_ab_viewnews

- www.noridianmedicare.com/shared/partb/bulletins/2007/238_jul/Evaluation_and_Management_Clarification_.htm.