E/M Coding Alert - 2014 Issue 37
Part B Documentation: New MAC Tip Reminds Practices What the Nurse Can--and Cannot--Document
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Article Overview
This article reviews a Medicare Part B documentation update focused on evaluation and management records. It explains the general roles of physicians, nonphysician practitioners, ancillary staff, and scribes in documenting patient encounters, and it summarizes how Medicare contractors frame those documentation boundaries. The piece is relevant to practices that rely on nursing staff, triage workflows, or scribe arrangements and need to understand documentation expectations for compliant recordkeeping.
Why This Topic Matters
Documentation roles can affect whether an E/M note supports billing and whether the record reflects work performed by the correct clinician. Practices that use ancillary staff or scribes need this guidance to reduce documentation risk and maintain compliant medical records.
Article Sections
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Ancillary staff documentation limits
This section discusses which parts of a Medicare record may be documented by ancillary staff and how those limits relate to E/M documentation.
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Triage nurse documentation and HPI follow-up
This section covers the special handling of information collected during triage and the need for physician or NPP review and follow-up in the record.
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Other payer guidance on HPI documentation
This section summarizes related documentation guidance from another Medicare contractor and compares acceptable and unacceptable documentation approaches at a high level.
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What about scribes?
This section explains how Medicare distinguishes scribe documentation from other forms of staff-assisted recordkeeping in various encounter types.
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Facility setting and billing considerations
This section addresses how facility-based encounters involving an NPP and physician signature are handled from a documentation and billing perspective.
What You Will Learn
- How Medicare contractors distinguish between physician/NPP documentation and ancillary staff documentation
- How triage-related information is treated in the medical record
- How scribe arrangements are described in Medicare documentation guidance
- How facility-based note creation can affect billing responsibility and record attribution
Who Should Read This
- Physicians
- Nonphysician practitioners
- Medical coders
- Medical billers
- Practice managers
- Compliance staff
- Clinical documentation staff
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