Otolaryngology Coding Alert

Question: My co-worker thinks a physician must take a patient's history, while I think a nurse can perform this duty. Who's right?

California Subscriber

Answer: You're both partially right. Any employee can take part of 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 frontdesk staff member or the patients (via questionnaire) may even perform the function. The ENT or a nurse practitioner (NP), however, must complete the history of present illness (HPI).

Be careful: To receive credit for these historical elements as the ENT completes the E/M service, he must date and sign the patient's chart to indicate he reviewed the entire history note. Documentation may include a notation supplementing or confirming the information that others recorded.

Check your state requirements. For instance, some states require the physician to sign off on any incidentto services, such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), as well as higher-level E/M services such as 99212-99215, provided by mid-level providers (for instance, an NP). Other states do not require the physician to sign off on incident-to services, but they do have to create the plan of care.