Neurosurgery Coding Alert

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


Louisiana 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, or the patient may do it himself on a medical questionnaire. The neurosurgeon or nurse practitioner must complete the history of present illness, however.

Be careful: The neurosurgeon must indicate in the patient's progress note that he reviewed the history notes. The physician must also sign off if the history is done as part of 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). Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.