Neurology & Pain Management Coding Alert

Question: Must the neurologist take a patient's history, or can a nurse or other nonphysician staff record the history prior to the neurologist meeting the patient?


California Subscriber


Answer: Any employee can take the history. In fact, the E/M service documentation guidelines state that ancillary staff may record the review of systems and/or past family social history. Although nurses often record this information, a front-desk staff member may even perform the function. The neurologist or nurse practitioner, however, must complete the history of present illness.

Be careful: The neurologist must sign off on the patient's chart and must indicate that he reviewed the history notes. 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 ...) and all other E/M services (e.g., 99212-99215).