E/M:
Nail Down Answers to E/M Documentation Questions
Published on Tue Oct 12, 2010
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 AreasThe 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 [...]
