tci Medicare Compliance & Reimbursement - 2007 Issue 39

DOCUMENTATION: Are Your Nurses' History Notes Becoming Audit Bait?

Nurses can document chief complaint, but history should be in doctor's handwritingWarning: 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...

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