Neurosurgery Coding Alert

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

Mississippi Subscriber

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