General Surgery Coding Alert - 2010 Issue 31
Documentation: Watch Out: Nurse's History Note Might Be Audit Bait
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Article Overview
This article explains Medicare documentation topics affecting evaluation and management records, with emphasis on what portions of a history may be documented by nursing staff, how physician review is expected to appear, and what payers say about scribe documentation and attestation. It also summarizes CMS signature guidance and references related Medicare policy updates and carrier commentary. The content is aimed at physicians, non-physician practitioners, coders, auditors, and compliance staff who support documentation integrity and billing compliance.
Why This Topic Matters
Documentation signatures, review statements, and source attribution can affect whether an E/M service supports payment during medical review. Understanding payer expectations helps practices reduce denials and avoid audit risk.
Article Sections
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Nurse documentation and physician review
Covers payer guidance on documentation performed by nursing staff and the need for provider review in the medical record. Discusses broad expectations for history-related documentation in evaluation and management visits.
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What about scribes?
Explains general requirements for scribe-documented records and provider oversight. Addresses how practices should think about authorship, review, and identification of the scribe in the chart.
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Get to know signature requirements
Summarizes CMS guidance on signatures and attestation statements for Medicare medical review. Includes mention of a CMS MLN Matters update and general compliance expectations for signed records.
What You Will Learn
- How payer guidance affects documentation attribution in evaluation and management records
- What general types of history information may be documented by nursing staff
- Why provider review and authentication matter for chart integrity
- How scribe documentation is treated under Medicare-oriented compliance guidance
- What CMS signature and attestation guidance means for medical record documentation
Who Should Read This
- Physicians
- Non-physician practitioners
- Medical coders
- Compliance staff
- Practice managers
- Medical auditors
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