General Surgery Coding Alert - 2017 Issue 5
You Be the Coder: Who can Record the PFSH?
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Article Overview
This premium Q&A article addresses whether nursing-entered past medical, family, and social history can be used to support documentation requirements under CMS documentation guidelines. It is intended for coding professionals, compliance staff, and clinicians who work with evaluation and management documentation and need to understand how review and update requirements are documented in shared or institutional records.
Why This Topic Matters
Accurate handling of history documentation affects evaluation and management record support, compliance review, and the acceptability of information entered by staff other than the billing provider.
What You Will Learn
- How the article frames use of ancillary staff documentation in history-taking
- The role of physician review and update in shared medical records
- General CMS documentation guidance related to past medical, family, and social history
- How institutional or group-practice recordkeeping can affect documentation support
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians and other billable providers
- Clinical documentation staff
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