The only parts of the E/M visit that an RN can document independently are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to a June 4, 2010 Frequently Asked Questions (FAQ) answer from Palmetto GBA, Part B carrier for Ohio. The physician or mid-level provider must review those three areas and write a statement that the documentation is correct or add to it.
Only the physician or non-physician practitioner who conducts the E/M service can perform the History of Present Illness (HPI), Palmetto says.
Exception: In some cases, an office or Emergency Department triage nurse can document “pertinent information” regarding the Chief Complaint or HPI, Palmetto says. But you should treat those notes as “preliminary information.” The doctor providing the E/M service must “document that he or she explored the HPI in more detail,” Palmetto explains.
Other payers have expanded on Palmetto’s announcement, letting physicians know that they cannot simply initial the nurse’s documentation. For example, Noridian Medicare publishes a policy that states, “Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be ‘I have reviewed the HPI and agree with above.’”
Good news: Thanks to this clarification, your doctor won’t have to repeat the triage nurse’s work. Right now, if the nurse writes “knee pain x 4 days,” at the top of the note, some auditors might insist that your doctor needs to write “knee pain x 4 days” in his/her own handwriting underneath. But that requirement is a thing of the past if your carrier echoes Palmetto’s requirement.
Bad news: Now this carrier has made it…