Pulmonology Coding Alert

Every doctor should own up to a patient's history of present illness.Ancillary staff (i.e., registered nurses [RN] and licensed practical nurses [LPN]) can be handy in documenting the history for an E/M encounter, but not past the review of systems (ROS); past, family, and social history (PFSH); and vital signs. From this point on, it's the physician's job to review and verify the authenticity of the information provided. In addition, only the physician who carries out the E/M service should perform and document the history of present illness (HPI).Example: A patient shows up in the office with early signs of pneumonia (480-486). The nurse notes down "cold and high fever for the last three days," and takes the patient's ROS, PFSH, and vital signs. When the patient sits down with the pulmonologist, the physician performs the HPI and expands on what the nurse has noted. He orders a chest x-ray [...]