tci Part B Insider - 2007 Issue 33

DOCUMENTATION: Watch Out--Nurse's History Note Could Be 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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