Pediatric Coding Alert

Although support staff might want to lighten the pediatrician's preservice load, one history element must remain the physician's domain for clinical and compliance reasons.

You're not alone if you've read and reread the E/M documentation guidelines looking for the definitive answer to who can perform the HPI. In many pediatric practices, a nurse takes a patient's past, family and social history (PFSH) and review of systems (ROS). The pediatrician 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's guardian 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 state.

For instance, if a pediatrician 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.

Catch this: The absence of any HPI performer statement indicates ancillary staff does not have permission to collect the HPI, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. The E/M guidelines specifically state that ancillary staff can collect ROS and PFSH. If the AMA and CMS had extended HPI permission to staff, the guidelines would have included this allowance.

In fact, physicians actually get paid for this work if the payer uses the Medicare Physician Fee Schedule. CMS explained that the E/M service code values include physician work for performing the HPI, says Mary Pat Johnson, COMT, CPC, COE, senior consultant for Corcoran Consulting Group.

Your office can involve staff 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.

Scribe allowed: The nurse may record the HPI as the physician dictates and performs it. In this case, the doctor 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 one carrier.

Auditors 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: Your pediatrician 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.