tci ED Coding & Reimbursement Alert - 2002 Issue 4

Reader Question: Gathering HPI

Question: I am confused about whether the information that nurses gather during triage can be used in the documentation of the history of present illness (HPI) portion of the patient's history. This is generally recorded on our preprinted forms, which are then given to the physician. But I've also been told that the doctor must personally do the HPI. Which is correct?Wisconsin Subscriber Answer: Under Medicare guidelines, the physician must personally conduct the HPI in order to have that information factored into the E/M service level assigned for the ED visit (99281-99285). However, the physician is allowed to...

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