Orthopedic Coding Alert

The physician must indicate that he or she reviewed any nurse's notes.Warning: Don't let your nurses do the doctor's work, or you could wind up with a non-payable visit.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 June 4, 2010 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 it.Only the physician, physician assistant (PA), or nurse practitioner (NP) 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 [...]