tci ED Coding & Reimbursement Alert - 2002 Issue 9

Reader Question: History of Present Illness

Question: Can the history of present illness (HPI) elements be obtained from the nurse's assessment note? The physician does not sign off on this document. I'm only coding the physician component of the ED visit. I was under the impression that if the physician reviewed and agreed with the nurse's notes (and documented her review), then the HPI elements could be used. North Carolina SubscriberAnswer: The HPI elements cannot come from the nurse's notes. Most experts agree that because CMS hasn't explicitly stated that someone other than the physician can do the HPI, this means that a physician is...

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