Otolaryngology Coding Alert

Question: Ancillary staff record review of systems (ROS) and patients- past family social history (PFSH) using electronic medical records (EMR). Is there an acceptable statement the otolaryngologist should use to indicate he reviewed this information?

Kansas Subscriber

Answer: The staff member can record the ROS and PHSH before the ENT sees the patient. The physician can still get credit for it, as long as she references that she reviewed that information and creates a direct link to the source. Here are some ways your ENT can do that:

Step 1. The physician should co-sign and date the form(s).

Step 2: The ENT should make a statement in the chart note (dictation or handwritten) that he reviewed and agreed with the ROS and PFSH or disagreed with it and why. The physician may also refer to the history form within the progress note.

Step 3: In the statement, the physician should exactly identify the referenced form, otherwise an auditor may not count the form's information. Signing and dating the form as in step 1 further illustrates the ROS and PFSH to which the ENT refers. The auditor should give credit for the ROS and PFSH if the physician creates some type of direct link to the source document.

Consider creating a status statement, such as "I reviewed form [name] completed on [date] by a staff member. There are no updates or changes at this visit."

Catch: The physician must take the history of present illness (HPI). Ancillary staff cannot perform this function.