Urology Coding Alert

Question: My coworker thinks the urologist must take a patient's history, but I think a nurse can perform this duty. Who's right?


California Subscriber

Answer: Any employee can obtain a part of the patient's history. In fact, the E/M service documentation guidelines state that ancillary staff may obtain and record in the medical records the review of systems (ROS) and past medical, family, and social history (PFSH).

Although nurses often record this information, a front-desk staff member may even perform the function. The urologist, however, must obtain and completely record the history of present illness (HPI), although he can obtain additional information concerning the HPI from the nurse's or medical technician's notes. But a statement such as "history reviewed and unchanged" is not acceptable on audit review, and no credit for obtaining the HPI will be given in this case.

Be careful: The urologist must indicate that he reviewed these history (ROS and PFSH) notes. Documentation should include a notation supplementing or confirming the information that others recorded as well as the urologist's signature and the date reviewed and signed.

To ensure compliance and good medical record-keeping, make sure the physician signs off on any incident-to services, such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), as well as higher-level E/M services (e.g., 99212-99215).