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Pediatric Coding Alert

Reader Questions:

Physician Should Document HPI

Published on Tue Mar 21, 2006

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


Idaho 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 family social history, but HPI is not listed among them.
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