Wiki Medical assistant scope of practice

CatchTheWind

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If a medical assistant sees the patient without a doctor in the room for services that are within her scope (injection, suture removal, bandage change, etc.), how much is she permitted to actually do? ie:

Can she perform and document a brief exam of the affected area?
Can she perform and document a pertinent HPI?
Can she consult with the doctor about the plan of care and then document his plan?
 
From CMS guidelines:

"Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information."

Per my local MAC (Noridian):

"Noridian Healthcare Solutions (Noridaian) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when "physician" criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name."

First Coast:

Q. If my office uses an E/M questionnaire for the Past, Family and Social History (PFSH) and Review of Systems (ROS), is it mandatory that the physician sign and date the form?
A. The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be notation supplementing or confirming the information recorded by others.


CGS


Because ancillary staff is not considered credentialed providers, Medicare does not recognize their documentation and billings. The provider must attest and document as described above, however I couldn't readily find anything else from First Coast/CMS that hints any further. Generally I heard that ancillary staff could only document the Chief Complaint, ROS, PFSH, vitals and nothing else. My MAC gives a little leeway with HPI, but I don't see anything else for the Exam and MDM.
 
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Thanks. I was not referring to E/M visits, but to visits which are performed in full by a medical assistant, such as injection, suture removal, or bandage change.

Can anyone answer the question on that? Thanks!
 
A medical assistant can and should, document any information relevant to the services they perform in a visit. What they are allowed to perform, i.e. their scope of practice, is governed by state law and so will vary somewhat depending on where the practice is located. Your state's board of nursing or other licensing agency that certifies medical assistants should have this information available on their web site or would be able to provide it for you if you contact them. I'm not sure I understand why it would be a concern, though, for them to be performing and documenting these particular things that you describe if this is not part of a physician E&M service. Assessing a patient within scope, communicating with the provider, and documenting the findings or observations from the visit is a normal part of ancillary staff duties.
 
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From CMS guidelines:

"Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information."

Per my local MAC (Noridian):

"Noridian Healthcare Solutions (Noridaian) reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or non-physician practitioner when "physician" criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The ancillary staff may write down the HPI as the physician dictates and performs it. The physician shall review the information as documented, recorded or scribed and writes a notation that he/she reviewed it for accuracy, did perform it, adding to it if necessary and signing his/her name."

First Coast:

Q. If my office uses an E/M questionnaire for the Past, Family and Social History (PFSH) and Review of Systems (ROS), is it mandatory that the physician sign and date the form?
A. The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be notation supplementing or confirming the information recorded by others.



CGS


Because ancillary staff is not considered credentialed providers, Medicare does not recognize their documentation and billings. The provider must attest and document as described above, however I couldn't readily find anything else from First Coast/CMS that hints any further. Generally I heard that ancillary staff could only document the Chief Complaint, ROS, PFSH, vitals and nothing else. My MAC gives a little leeway with HPI, but I don't see anything else for the Exam and MDM.
Hello

Any idea how this woud apply now that we are being pushed to Telehealth due to COVID 19? Can the Medical Assistant call the patient for CC and medical history?
 
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