tci Part B Insider - 2010 Issue 31

Documentation: Watch Out: Nurse's History Note Might Be Audit Bait

The physician must indicate that he or she reviewed any nurse's notes.Warning: Don't let your nurses do the doctor's work, or you could wind up with a non-payable visit.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, a Part B carrier. The physician or mid-level provider must review those three areas and write a statement that the documentation is correct or add to it...

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