Pulmonology Coding Alert

Question: My coworker thinks a pulmonologist must take a patient's history, but I think a nurse can perform this duty. Who's right?


California Subscriber

Answer: Any employee can take 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 front-desk staff member or the patients themselves via questionnaire may even perform the function. The pulmonologist or nurse practitioner, however, must complete the history of present illness (HPI).

Be careful: The pulmonologist must date and sign the patient's chart in an effort to support that he reviewed the history notes in order to receive credit for these historical elements as he completes the E/M service. Documentation may include a notation supplementing or confirming the information that others recorded. Make sure the pulmonologist signs off on any incident-to services, such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), as well as higher-level E/M services provided by mid-level providers (such as, 99212-99215).