Pediatric Coding Alert

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

California Subscriber Answer: Any employee can take two elements of the history. In fact, the E/M services documentation guidelines state that ancillary staff may record the review of systems and/or past family social history. Although many offices have a nurse record this information, a front-desk staff member or a parent may even perform the function. The pediatrician or nurse practitioner, however, must complete the history of present illness.
 
Be careful: The pediatrician must sign off on the patient's chart and must indicate that he reviewed the history notes. Documentation should include a notation supplementing or confirming the information others recorded. The physician's signature is necessary for documentation of 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 (e.g., 99212-99215).