Neurology & Pain Management Coding Alert

Question: If a nurse documents the history of present illness (HPI) in her notes, and the neurologist documents that he read the notes and agrees, can we count this as the physician's HPI? Or must the neurologist perform the HPI himself?

Idaho Subscriber

Answer: According to Medicare's 1995 and 1997 Documentation Guidelines, the physician must personally perform the HPI during an E/M visit.
 
Both the 1995 and 1997 guidelines state that ancillary staff (such as nurses) can perform other E/M history components, such as the review of systems and past family social history, but HPI is not listed among them.