ED Coding and Reimbursement Alert

Question:  If past medical, surgical, social, and family history are documented by the RN, do you need to specifically identify that you have reviewed that information to get credit, or does the final signing off of your chart denote recognition of all information contained in the chart as reviewed?

This has come up with our EHR charting, because the RN’s will often enter the PFSH, there is a check box to indicate you have reviewed and confirmed that information, and you can also add additional information.

Your thoughts are appreciated.

Answer: Below is the quote from the Medicare 1995 Documentation Guidelines:

DG: 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.

Payers have applied this as typically requiring confirmation of the material reviewed by ancillary staff.