tci Medicare Compliance & Reimbursement - 2014 Issue 21

Part B Documentation: Heed This MAC Tip on Documentation by Ancillary Staff

Warning: Consider nurse’s documentation as only preliminary information. If your physician simply initials what the nurse recorded, your reimbursement could be at stake. Part B MAC Palmetto GBA issued a new E/M tip recently, reminding doctors what ancillary staff members can document in your Medicare records and what must be recorded by the physician providing the service. “Ancillary staff may only document the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs,” indicates the latest tip published on Sept. 23. As for the history of present illness, leave that to the physician...

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