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I know that this has been discussed many times before, but the more I read the more confused I get. I copied the information below from the Palmeto GBA Medicare site. It seems that every "clarification" from Medicare creates more questions. So is this saying that the nurse can document the CC as long as the doctor gives more info in the HPI. Would we be able to count what the nurse says in the CC toward the HPI requirements, or would the doctor have to repeat what the nurse said. For example: Our nurse might say abdominal pain for 3 days, and then the doctor expands on that statement in the HPI. It is my understanding that you can pick out the required elements from the combined CC and HPI to get the required coding elements for the History of the Present Illness. Would I be
able to use location and duration if the doctor did not restate the nurses comments?

It seems to me as if this statement has conflicting statements?

What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an evaluation and management (E/M) encounter? Can ancillary staff act as a scribe for a provider?

Ancillary staff may only document:

Review of Systems (ROS)
Past, Family and Social History (PFSH)
Vital Signs

These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can perform the History of Present Illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the Chief Complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.


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