Oncology & Hematology Coding Alert

Guidelines and an FAQ response offer insights on who's responsible.

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

Limit RN Documentation to Listed Areas

The only parts of the E/M visit that an RN can document independently are the Review of Systems (ROS); Past, Family, and Social History (PFSH); and Vital Signs, according to a Frequently Asked Questions (FAQ) answer from Palmetto GBA, a Part B carrier. The physician or mid-level provider must review those three areas and write a statement that the documentation is correct or add to the documentation. Only the physician or non-physician practitioner who conducts the E/M service can perform the History of Present Illness (HPI), Palmetto adds.

Straight from the source: The 1995 E/M guidelines state, "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."

The 1997 guidelines include the exact same wording as above. In addition, the 1997 guidelines refer to documentation by ancillary staff in another section, which describes requirements  for the "constitutional" element of the exam: "Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)." You can download the documentation guidelines from www.cms.gov/MLNEdWebGuide/25_EMDOC.asp

Watch out: Check your state requirements. For instance, some states require the physician to sign off on any (or a certain percentage of) incident-to services, such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), as well as higher-level E/M services, such as 99212-99215, provided by mid-level providers (for instance, an NP). Other states do not require the physician to sign off on incident-to services, but the physician does have to create the plan of care.

Watch for Triage Nurse 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.

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

Bad news: Now this carrier has made it clear that your doctor can't get credit for HPI unless he elaborates on what the triage nurse wrote. In the above case, the doctor needs to note more information about the patient's four-day history of vomiting for the entry to count in the HPI.

Not everybody greets the Palmetto FAQ with open arms.

This clarification may cause more confusion because there's no definition of the word "preliminary." If all of the nurse's information is complete and accurate, what additional information the physician could add to the note is unclear.

What About Scribes?

In many practices, the physician dictates his findings to a mid-level provider who acts as a "scribe," documenting the information as the physician says it. Medicare payers also maintain specific rules for this type of arrangement. "When using a scribe, it's important to keep in mind that the scribe cannot interject any personal observations," says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding education and documentation compliance with UPMC in Pittsburgh, Pa. "The scribe is merely documenting the services done by the physician and observed by the scribe," she adds.

Tip: Be sure the scribe is clear when documenting that she is recording the information as stated by the physician in his own words. Think of it as a real time transcriptionist. If this is done in any other way it is inappropriate.

Also keep in mind who is acting as the scribe. Non-physician practitioners would not typically perform this role. As stated in Palmetto GBA's Medicare Bulletin January 2007,pg. 19: "Of particular importance, please note that evaluation and management services documented by a nonphysician practitioner/physician extender (such as a nurse practitioner or physician assistant) for work that he/she actually performs independently then is later reviewed/cosigned by a physician is not a scribe situation."

In a true scribe situation, the physician must review the scribe's documentation, and then sign the note "indicating that it has been reviewed and he/she is in agreement," Berman says. "This authenticates the note and is a requirement for billing purposes."

Palmetto and many other Medicare payers require that the scribe's name be identified in the medical records, says Berman.

Get to Know Signature Requirements

Effective March 1, CMS updated its signature requirements, outlining the rules that you must follow to meet Medicare's documentation requirements. Among the list of acceptable signatures are items such as a legible full signature, a legible first initial and last name, or an illegible signature if the latter is accompanied by an attestation statement. In MLN Matters article MM6698, CMS states that "to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary."

CMS offers the following example of an attestation statement, but notes that using this format is not specifically required: I, [print full name of the physician/practitioner], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [insert provider credentials, e.g., M.D.] when I treated/ diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

For more on CMS's signature requirements, visit www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf, and see Oncology and Hematology Coding Alert, vol. 12, no. 4.