Anesthesia Coding Alert

The physician must indicate that he or she reviewed any nurse's notes.Caution: Don't let your nurses do the doctor's work, or you could end 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 Palmetto GBA, a Part B carrier. The physician or mid-level provider must review those three areas and write a statement that the nurse's 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 adds.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 [...]