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Medicare Compliance & Reimbursement

DOCUMENTATION:

Are Your Nurses' History Notes Becoming Audit Bait?

Published on Tue Sep 18, 2007

Nurses can document chief complaint, but history should be in doctor's handwriting

Warning: Don't let your nurses do the doctor's work, or you could wind up with a non-payable visit.

The Centers for Medicare & Medicaid Services (CMS) has just clarified the role of nurses and other ancillary staff in evaluation and management documentation. If you're not up to date on the latest CMS guidance, your physician's documentation could fall apart.

The only parts of the E/M visit that an RN can document are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to a new Frequently Asked Questions (FAQ) answer from Palmetto GBA. The carrier said it had received a new clarification from CMS. The physician must review those three areas and either write a statement that the documentation is correct or add to it.

Only the physician or non-physician practitioner who conducts the E/M service can perform the History of Present Illness (HPI), Palmetto adds.

Exception: In some cases, an office or Emergency Department triage nurse can document "pertinent information" regarding the Chief Complaint or HPI, Palmetto says. But you should treat those notes as "preliminary information." The doctor providing the E/M service must "document that he or she explored the HPI in more detail," Palmetto explains. And the nurse must be an employee of the physician.

This issue is "the biggest can of worms of all," says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, TN.

It's common for ancillary staff to write the Chief Complaint "as they perceive it at the top of the note," says Eric Sandhusen, director of reimbursement, HIPAA and fiscal compliance with the Columbia University Department of Surgery.

Good news: Thanks to this clarification, your doctor won't have to repeat the triage nurse's work. Right now, if the nurse writes "knee pain x 4 days," at the top of the note, some auditors might insist that your doctor needs to write "knee pain x 4 days" in his own handwriting underneath. But that requirement is a thing of the past.

Bad news: Now CMS has made it clear that your doctor can't get credit for HPI unless he/she elaborates on what the triage nurse wrote, Sandhusen adds.

In the above case, the doctor needs to note more information about the patient's four-day knee pain. Otherwise, the nurse's entry will count for Chief Complaint but not for HPI.

If the doctor doesn't elaborate on the history, you won't get credit for even a "problem focused" history. Thus, your documentation would be inadequate for even a level one new patient visit, consult or initial inpatient visit. And established patient visit levels would have to depend on the level of exam and medical decision-making only.

"No one at CMS ever said the nurse couldn't write some HPI info down, in the ED setting or elsewhere," says Wilkinson. But CMS has said that unless the doctor writes the HPI info down a second time, the nurse's documentation won't count toward the requirements for HPI elements.

As for Chief Complaint, E/M guidelines only say that it must be recorded clearly--not who must record it. It would be "beyond ridiculous if a nurse can't even write 'headache,'" Wilkinson notes.
 
Not everybody greets the Palmetto FAQ with open arms. This clarification may cause more confusion, because there's no definition of the word "preliminary," worries Larry Levine, a certified coder in Washington, DC. CMS and Palmetto don't explain how much extra documentation could be required to comply with the guidelines.

For example: An office nurse could document, "Patient comes to follow-up for Type 2 DM, HTN, hypertriglyceridemia, allergic rhinitis, morbid obesity. Pt. reports taking meds consistently, and FBS this AM was 97. Pt. presently has no specific complaints," notes Levine. If all that information is complete and accurate, what else does the doctor have to add?

"I think Palmetto needs to provide specific documentation examples," says Levine.

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