From
CMS guidelines:
"
Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information."
Per my local MAC (
Noridian):
"
Noridian Healthcare Solutions (Noridaian) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when "physician" criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name."
First Coast:
Q. If my office uses an E/M questionnaire for the Past, Family and Social History (PFSH) and Review of Systems (ROS), is it mandatory that the physician sign and date the form?
A. 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 notation supplementing or confirming the information recorded by others.
CGS
Because ancillary staff is not considered credentialed providers, Medicare does not recognize their documentation and billings. The provider must attest and document as described above, however I couldn't readily find anything else from First Coast/CMS that hints any further. Generally I heard that ancillary staff could only document the Chief Complaint, ROS, PFSH, vitals and nothing else. My MAC gives a little leeway with HPI, but I don't see anything else for the Exam and MDM.