Ob-Gyn Coding Alert

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