I recently started working for a facility that never had a certified coder, and I am finding quite a few things that need to be....cleaned up, shall we say? The current issue I am working on is finding out if it is acceptable for a nurse to perform/document a patient's physical exam, if the patient is doing a telehealth visit with the physician. I had previously found documentation stating that the physician should personally perform the exam, but now I can't find it, and my boss wants proof in black and white to take to legal. Where can find the documentation I need to support my case?
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Wiki Can the nurse perform/document the exam for a physician?
- Thread starter LoraSales
- Start date
Mayzoo
Expert
A nurse can perform a 99211, but above that, a physician (PA, NPP, etc must perform/document/dictate the exam):
I am sure CMS has a page, but it did not pop up immediately.
Instead, when the information is already documented, billing practitioners can review the information, update or supplement it as necessary, and indicate in the medical record that they have done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (HPI, Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits.
CMS notes that it has never addressed who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.
The physician must still personally perform the physical exam and medical decision-making activities of the E/M service being billed."
"Under that system, the only Evaluation and Management (E/M) code that a Registered Nurse can bill to is 99211."
I am sure CMS has a page, but it did not pop up immediately.
Regulatory clarification
"In both the Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2019 (PDF) (CMS, 2018) and an additional FAQ (PDF) (CMS, 2018), CMS expanded current documentation policy applicable to office/outpatient E/M visits. Starting Jan. 1, 2019, any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the patient does not need to be re-documented by the billing practitioner.Instead, when the information is already documented, billing practitioners can review the information, update or supplement it as necessary, and indicate in the medical record that they have done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (HPI, Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits.
CMS notes that it has never addressed who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.
The physician must still personally perform the physical exam and medical decision-making activities of the E/M service being billed."
"Under that system, the only Evaluation and Management (E/M) code that a Registered Nurse can bill to is 99211."
Last edited:
SharonCollachi
Guest
Uh, if it's a telehealth visit, how is ANYONE doing the physical exam at all?
This is a behavioral health/substance abuse facility, where the patients are inpatient. They go to the nurse, the nurse performs the vitals and such, and enters the information. The patient then does a telehealth with the APRN. Not sure if the nurse stays in the room during the telehealth visit or not. As I said, I am new to this organization, and I am trying to figure out exactly WHAT they do, and what parts of it are right/wrong.