# Hospital E/M Documentation



## OliviaPrice (Jan 30, 2013)

I'm needing to know if this is appropriate:

We have RN's that assist our physician's in the hospital with their rounding.  The RN will go in to visit with the patient and obtain a "Pre-assessment" of the patient (the intent here is to identify any emergent cases for the physician).  The RN will perform a full HPI, ROS, PFSH, exam and an initial assessment.  The RN will document all this information into the EMR and hold the note.  

The physician will then present bedside to the patient and perform his/her own HPI, exam and assessment.  The physician will take the note the RN documented, make his/her additions/deletions/revisions and electronically sign the note.

Both the RN & physician's electronic signature will appear on the report with a date & time stamp.

My question.....
1) Is this documentation acceptable for the physician to bill his level of service considering the original information was obtained and documented by the RN?
2) Would it be of any concern or benefit if the physician added a statement of "I personally examined and interviewed the patient and agree with the exam and note." at the bottom of the note?


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## MikeEnos (Jan 30, 2013)

To answer your question: Yes, it is acceptable to count the ROS and/or PFSH elements.  The rest of the documentation must be documented by the provider, which you said was done.  This quote comes straight out of the 1995 Documentation Guidelines for Evaluation and Management Services.



> 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



Here's the link


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## mitchellde (Jan 30, 2013)

It is ok for the nurse to capture the ROS as long as the provider documents it was reviewed.  However the RN may not document any other part of the visit.  So to answer questions 1 and 2 ... no, the RN may not document the encounter and have the provider make adjustments and sign it, nor can the RN document the encounter and the provider just sign the note.


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## LLovett (Jan 31, 2013)

I'm with Debra on this, this scenario is not acceptable.

Unless the RN is a NP then this is completely out of scope of practice for an RN. RNs cannot be utilized like a resident or mid-level provider.

The only documentation the RN can get in this scenario is the CC, ROS, PFSH, and vitals.

Laura, CPC, CPMA, CEMC


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## OliviaPrice (Jan 31, 2013)

Thanks for the responses, my initial reaction was that the RN's should absolutely not be doing this.  But....after speaking to the physicians.....they are in fact completing the HPI, exam and the MDM.  They pushed back on why is it necessary to delete what the nurse documented just to re-type the documentation if their findings were exactly the same.  

Thoughts?


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## kbarrf (Jun 6, 2013)

We do agree the Hospital RN  can document the CC ROS and the PFSH. Does the physician have to employ the nurse or can the nurse be an employee of the hospital?


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## mitchellde (Jun 6, 2013)

for the nurse to capture the ROS PFSh and vitals she/he must be an employee of the physician.  I was always told the CC must identified by the physician.


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## cheermom68 (Jun 7, 2013)

Even if the provider agrees with the nurses assessment, he must completely restate his findings.  Only the information documented by the provider can be used to determine the level of service.  It is also not within the RN scope of practice to perform the other elements.  This could also be an issue if a malpractice case came up.


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## kellibeasley (Nov 12, 2013)

What if the RN were a PA, and the DR face to face occured the next day.  
1. is it still ok to bill under the Dr's NPI using the Split/shared concept and utilizing the documentation made by the PA the day prior?
2. What day would the initial visit be billed?


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## wrightju1 (Nov 12, 2013)

If the doctor did not see the patient face to face, then no service was provided that day.  As far as carrying forward information, is this a subsequent hospital care for this provider?  Then History is a non-issue.  But if this is an Initial Hospital care it sounds like pretty shoddy health care to me documenation and rules aside.


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## Peter Davidyock (Nov 18, 2013)

I just posted a new thread about shared/split visits.
Here is a copy.
Hope it helps:

Evaluation & Management: Split/Shared E/M 

The following information is provided to assist in the appropriate documentation of split/shared E/M inpatient/outpatient hospital services.

When an E/M service is performed in the hospital inpatient/hospital outpatient or emergency department and is shared between a physician and a NPP from the same group practice, the service may be billed as a split/shared E/M service.  The split/shared service may be reported to Medicare using either the physician's or the NPP's Unique Physician Identification Number (UPIN), Provider Identification Number (PIN), and National Provider Identifier (NPI) number.

In order to report the service under the physician's UPIN/PIN/NPI number, the physician must meet multiple requirements.  Those requirements are:
 •The physician must provide a face-to-face encounter with the patient;
 •The physician must document at least one element of the history, exam and/or medical decision making component of the E/M service;
NOTE:  It is not sufficient for the NPP to document the physician involvement and then the physician document â€œseen and agreeâ€� or simply countersign.  The physician must document what he/she personally performed during the E/M service;
 •The physician must legibly sign the medical record (electronic signatures are acceptable) to justify involvement in the patient care; and
 •The physician and the NPP must be actively involved in the Medicare Program and have a valid UPIN/PIN/NPI number for reporting purposes. 

If any of the above are lacking in the patient's medical record, then the service may only be reported using the NPP's UPIN/PIN/NPI. Payment will then be made at the appropriate physician fee schedule rate based on the UPIN/PIN/NPI entered on the claim.  Please keep in mind that the following services may not be billed as split/shared services: 
 1. Critical Care services;
 2. Procedures; and
 3. E/M services performed in the skilled nursing facility (SNF)/nursing facility (NF). 

Other requirements that should be considered when billing for Split/Shared E/M services are: 
 •Any services provided by the NPP must be performed within the scope of his/her practice;
 •The E/M service must be â€œreasonable and necessaryâ€� as defined by Title XVIII of the Social Security Act, Section 1862(a)(1)(A);
 •The E/M service/level of care should be supported by using both the physician's and NPP's documentation;
 •The physician service and NPP service may occur jointly or at independent times throughout the day as long as they occur on the same calendar day; and
 •The duration of the E/M service should not control the level of care unless the following is documented in the medical record:  The total time spent in the encounter;
 More than 50% of the time providing the service was spent providing counseling or coordination of care; and a description of the content of the counseling or coordination of care. 

If an NPP or a Scribe is used for documenting purposes then the record requires 2 additional entries. One from the physician who performed the service:

Example: I, Dr. John Doe, personally performed the services described in this documentation, as recorded by Jane Smith RN in my presence, and it is both accurate and complete.
(Physician co-signs the medical note)
and one from the NPP/Scribe who recorded the service?
Example: I, Jane Smith RN am scribing for, and in the presence of, Dr. John Doe.
(Name of acting scribe for the physician)
For a split/shared service to be reimbursed by Medicare Part B, the supporting medical records must satisfy the documentation requirements found in the Internet-Only Manual (IOM) references. An inpatient Split/Shared Evaluation and Management (E/M) service is defined by the Centers for Medicare & Medicaid Services (CMS) IOM Publication 100-04, Chapter 12, Section 30.6.1(B), as an E/M service, "...shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient." Additionally, IOM Publication 100-04, Chapter 12, Section 30.6.13 (H) states that, "A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service."
Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed. When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E/M visit face-to-face with the same patient on the same date of service" as the portion of service performed by the NPP, a service billed under the physician's Provider Transaction Access Number (PTAN) will be denied.
It is of particular importance to remember that notes documented by the NPP for E/M services performed independently within a facility, and later reviewed and co-signed by the physician, depict neither a scribe situation nor an appropriate split/shared visit. Additionally, "incident to" guidelines do not apply to services in an inpatient setting. In this situation, the service should be billed under the NPP's provider number, and would be reimbursed at the established rate for that provider.
With the IOM requirements in mind, the following are examples of medical record documentation by the physician which would not be considered adequate to support a split/shared visit:
•	"I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM and agree with the assessment and plan as written" signed by the physician 
•	"Patient seen" signed by the physician 
•	"Seen and examined" signed by the physician 
•	"Seen and examined and agree with above (or agree with plan)" signed by the physician 
•	"As above" signed by the physician 
•	Documentation by the NPP stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a co-sign of the note by Dr. X 
•	No comment at all by the physician, or only a physician signature at the end of the note 
In conclusion, please remember that for a split-shared visit, there must be documentation of the face-to-face portion of the E/M encounter between the patient and the physician. The medical record should also clearly identify the part(s) of the E/M service which were personally provided by the physician, and which were provided by the NPP. In the absence of such documentation, the service may only be billed under the NPP's provider number per CMS IOM Publication 100-04, Chapter 12, Section 30.6.1 (B). This applies to the initial history and physical examination, the discharge summary, and subsequent hospital visits.


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