Pulmonology Coding Alert

Every doctor should own up to a patient's history of present illness.

Ancillary staff (i.e., registered nurses [RN] and licensed practical nurses [LPN]) can be handy in documenting the history for an E/M encounter, but not past the review of systems (ROS); past, family, and social history (PFSH); and vital signs. From this point on, it's the physician's job to review and verify the authenticity of the information provided. In addition, only the physician who carries out the E/M service should perform and document the history of present illness (HPI).

Example: A patient shows up in the office with early signs of pneumonia (480-486). The nurse notes down "cold and high fever for the last three days," and takes the patient's ROS, PFSH, and vital signs. When the patient sits down with the pulmonologist, the physician performs the HPI and expands on what the nurse has noted. He orders a chest x-ray to rule out pneumonia.

Forget about this important guideline and you'll be at risk for a denial.

Remember, the physician should always treat any information documented by the ancillary staff as "initial information," and support the reported visit level with an official entry, documenting his own HPI.

However, this general rule remains: HPI, medical decision making and examination are considered physician's work and not relegated to ancillary staff.

A Scribe May Do The Doctor's Work -- Sort Of

In some cases, a physician would ask his ancillary staff to act as "scribe," documenting the information as the physician dictates it. Most payers allow providers to use scribes but only to help in documenting the services performed by the physician.

CMS provides the following definition of a scribe: "A scribe is one who follows the doctor around and writes word for word, what the doctor says as he's examining the patient -- a sort of human tape recorder." Aside from nurses, medical students, physician assistants (PAs) or front desk staff could all act as a scribe.

A must: The physician should review the scribe's documentation, and then sign and date the note to supplement or confirm the information recorded by others. The scribe should also be identified in the medical records with the proper attestation and signature. For example, this attestation that could be used by the scribe: "Recorded by _______, acting as a scribe for Dr. _____ Date and signature."

What About EMRs?

Practices using electronic medical records (EMR) in their office recommend that the provider type the note or use customizable "auto-fills" to drop in commonly used notes while in the room. For physicians who don't wish to be "bothered" with this work, they may use following options:

• Have a scribe fill out the electronic medical record in the room.
• Have a member of staff type your paper notes into the electronic medical record after the visit.
• "Copy-paste" text received in a Word file from a transcription service into the electronic medical record.

Whether your practice is into EMRs or good old written medical records, you should keep in mind that a scribe acts as a "shadow" to the physician. She records all of the chart elements that you -- coders -- look for in deciding E/M levels and CPTs. The scribing activity must also be noted in the encounter note.

"Scribe guidelines emphasize that scribes are recording these elements strictly from physician direction. Like coders, scribes cannot assume that something was done without clear direction from the physician," says Jim Strafford, CEDC, MCS-P in his article Scribing: A Very Old and Up-to-date Profession for Coders published in the Amercian Academy of Professional Coders (AAPC) website (http://news.aapc.com) on October 6, 2010.

"Scribes also document consults with other physicians, review old records, labs, ordered diagnostics, and findings. An effective scribe documents all of the elements for the allimportant MDM element of documentation," adds Strafford.