Otolaryngology Coding Alert

Question: My co-worker thinks a physician must take a patient's history, while I think a nurse can perform this duty. Who's right? California Subscriber Answer: You're both partially right. Any employee can take part of the history. In fact, the E/M service documentation guidelines state that ancillary staff may record the review of systems (ROS) and/or past family social history (PFSH). Although nurses often record this information, a frontdesk staff member or the patients (via questionnaire) may even perform the function. The ENT or a nurse practitioner (NP), however, must complete the history of present illness (HPI). Be careful: To receive credit for these historical elements as the ENT completes the E/M service, he must date and sign the patient's chart to indicate he reviewed the entire history note. Documentation may include a notation supplementing or confirming the information that others recorded. Check your state requirements. For instance, some states [...]