Otolaryngology Coding Alert

CMS does make this element your ENT's territory Your ENT isn't wasting his time confirming a patient's history of present illness (HPI). Turns out it's his duty. You-re not alone if you-ve read and re-read the E/M documentation guidelines looking for the definitive answer to who can perform the HPI. Many practices allow a nurse to take the past, family and/or social history (PFSH) and review of systems (ROS), or allow a patient to complete a form detailing this information. The physician then obtains the HPI. If your practice wants to verify whether this is a proper use of everyone's time, you might be hard-pressed to find the guideline in writing. Here's where to turn and the requirements staff need to stick to. Get Clear Insight on 2 History Elements You may permit a staff member or even allow the patient to record the PFSH and ROS elements. This guidance stems from the AMA- and CMS-approved E/M guidelines. "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient," according to the 1995 and 1997 documentation guidelines for E/M services. Don't miss: The physician must document that he reviewed the PFSH and ROS history elements. The notation must supplement or confirm the information that others recorded, the guidelines stipulate. For instance, if an ENT reviews a patient-completed PFSH and ROS form, he could indicate his review "with a brief line, such as -I reviewed the history form filled out by the patient on Sept. 4, 2007,-" says Margaret M. Maley BSN, MS. He should also sign and date the form and retain it in the patient's medical record. Stop Hunting Here for HPI Guidance Because the E/M guidelines create concrete PFSH and ROS recording criteria, many people look to the same place for HPI reporting information. "The guidelines have never defined if the staff was allowed to document the history of present illness," says Teresa Thompson, CPC, CMSCS, CCC, a consultant in Carlsborg, Wash. Adhere to National Payment Policy Some Medicare carriers closed the door on any confusion in this area. A CMS carrier clarified that only the physician or nonphysician practitioner (NPP) who is conducting the E/M visit can perform the HPI and chief complaint (CC), according to Noridian's E/M clarification that appeared in Medicare B News Issue 238, July 10, 2007: "This is physician work and shall not be relegated to ancillary staff." Get this: You should always adhere to this guidance. "Although only some carriers published the policy, it is Medicare's national policy," says Mary Pat Johnson, COMT, CPC, COE, senior consultant for Corcoran Consulting Group. Why: Medicare bases its rationale on the fee schedule, Johnson says. The E/M service [...]