Urology Coding Alert

Question: I've heard that for an E/M visit, the physician is responsible for certain parts of that visit. Does Medicare state this explicitly?Answer: In the E/M service documentation guidelines, CMS states that ancillary staff or even the patient (via questionnaire) may record the review of systems (ROS) and past, family, and/or social history (PFSH) portions of the history component.Be careful: To receive credit for these history elements, your urologist should date and sign the patient's chart to indicate he reviewed the entire history note.Straight from the source: The 1995 E/M guidelines state, "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others."The 1997 guidelines include the exact same wording as above. In addition, the 1997 guidelines refer to documentation by ancillary [...]