Neurology & Pain Management Coding Alert

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


California Subscriber
Answer: Any employee can take a patient's history. In fact, the evaluation and management service documentation guidelines state that ancillary staff may record the review of systems (ROS) and/or past family social history (PFSH). Although nurses often record this information, you may even assign a front-desk staff member to perform the function.

Be careful: A physician or nurse practitioner, however, must complete the history of present illness (HPI). Your neurologist must also sign off on the patient's chart and must indicate that he reviewed the history notes. Documentation should include a notation supplementing or confirming the information that others recorded.

In addition, make sure that a physicians 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, such as 99212-99215.