tci Part B Insider - 2014 Issue 37

Part B Documentation: New MAC Tip Reminds Practices What the Nurse Can--and Cannot--Document

Hint: Documenting HPI is the job of the doctor or NPP. Your nurse might be quite adept at recording your documentation—but if she documents too much, your notes might not be applicable to your coding choices. That’s the word from a new E/M Tip that Part B MAC Palmetto GBA issued last week, reminding doctors what ancillary staff members can document in your Medicare records. “Ancillay staff may only document the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs,” the latest tip, published Sept. 23, indicates.  As for the...

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