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: Other payers have expanded on Palmetto's announcement, letting physicians know that they cannot simply initial the nurse's documentation. For example, Noridian Medicare publishes a policy that states, "Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be 'I have reviewed the HPI and agree with above.'" Good news: Bad news: Not everybody greets the Palmetto FAQ with open arms. This clarification may cause more confusion, because there's no definition of the word "preliminary." Palmetto does not 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." If all that information is complete and accurate, it's unclear what additional information the physician could add to the note. 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," reminds Suzan Berman, CPC, CEMC, CEDC, senior manager of coding education and documentation compliance with UPMC in Pittsburgh, Penn. "The scribe is merely documenting the services done by the physician and observed by the scribe," she adds. In addition, 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 must be identified in the medical records, confirms Berman. Get to Know Signature Requirements On June 16, CMS updated its signature requirements, outlining the rules that you must follow to meet Medicare's documentation requirements. Among the regs that CMS outlined in MLN Matters article MM698 is the statement that "in order 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 http://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf.