Part B Insider (Multispecialty) Coding Alert

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 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/her 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, Sandhusen warns. 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.