Pediatric Coding Alert

Question: I have always believed that any staff can take two of the history elements, but that the pediatrician or a nonphysician practitioner (NPP) must complete the history of present illness (HPI). Can you provide a source for this guideline?


Virginia Subscriber

Answer: CMS alludes to the HPI restriction in the E/M documentation guidelines. You won't, however, find this rule verbatim.

The guidelines directly address only two of the history elements--the review of systems (ROS), and the past, family and/or social history (PFSH). "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient," according to the 1997 Documentation Guidelines for E/M Services. The 1995 guidelines also include this directive on.

Neither guideline directly addresses staff members performing the HPI, which is the third part of history. Through the HPI omission, CMS implies that the pediatrician, NPP or other healthcare professional providing the E/M service must complete the HPI.