Pulmonology Coding Alert

In CMS's eyes, this element is your pulmonologist's duty. Although support staff might want to lighten the pulmonologist'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 history of present illness (HPI). In many pulmonology practices, a nurse takes a patient's past, family, and social history (PFSH) and review of systems (ROS). The pulmonologist 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 for guidance, and the requirements staff need to stick to. Sort Out History Territory You may permit a staff member, or even allow the patient or patient's guardian, to record the PFSH and ROS elements. [...]