tci Part B Insider - 2007 Issue 33

DOCUMENTATION: Watch Out--Nurse's History Note Could Be Audit Bait

Nurses can document chief complaint, but history should be in doctor's handwritingWarning: Don't let your nurses do the doctor's work, or you could wind up with a non-payable visit.The Centers for Medicare & Medicaid Services (CMS) has just clarified the role of nurses and other ancillary staff in evaluation and management documentation. If you-re not up to date on the latest CMS guidance, your physician's documentation could fall apart. The only parts of the E/M visit that an RN can document are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to...

To read the full article, sign in and subscribe to tci Part B Insider.


Keep pace with evolving Medicare regulations with timely analysis of critical updates interpreted in an easy-to-follow, easy-to-apply format. Your subscription to TCI’s Part B Insider will equip you to navigate code and guideline changes, CCI edits, and revisions to modifiers, the fee schedule, OIG target areas, and more.

  • Current newsletters added each month
  • Fully searchable archives - over 4800 articles
  • ALL years/issues back to 2003 organized by year and issue
  • Codes mentioned in articles are linked to Code Information pages
  • Code Information pages link back to related articles

This feature is currently unavailable for online purchase. For more information, please call 801-770-4203 or Contact Us.

demo
request yours today
subscribe
start today
newsletter
free subscription

Thank you for choosing Find-A-Code, please Sign In to remove ads.