Question Who Has Documentation Permissions per Medicare Guidelines?

KStaten

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Hello Everyone! :)

I am trying to put a table together to describe components of a medical document for a typical outpatient setting office visit and list who (per Medicare guidelines) has permission to document each one. In other words, in order to correctly bill under the physician, what components must he or she document him/herself?

Here's what I've drafted thus far... Does this look correct? If not, what changes do I need to make? THANKS!

[UPDATE: It has been pointed out (and understood) that the wording in this original table has been "more confusing than helpful." So, for clarification purposes, my poor choice of words, "PERMISSION TO DOCUMENT," was intended to mean Medicare allows this healthcare member to document AND Recognizes his/her documentation as counting towards the E/M level of service being billed. This is also referring to when strictly billing under the physician -- not incident-to billing-- as stated above in the original post. Additionally, this is with the assumption that scribes may also physically document the information provided, but that the content of the documentation must be supplied by one of the healthcare members listed. I have added this edit (and set it aside in brackets) to my original post and have left the remainder of the post in its original form for coherence of follow-up posts. Thank you, and, again, I apologize for the confusion! I appreciate all of your help and guidance!]


MEDICAL RECORDPERMISSION TO DOCUMENTPERMISSION TO DOCUMENT
COMPONENT NEW PATIENT OR ESTABLISHED PATIENT with NEW COMPLAINTESTABLISHED PATIENT with ESTABLISHED COMPLAINT
Chief Complaint (CC)Ancillary Staff, Physician, or PAAncillary Staff, Physician, or PA
Review of Systems (ROS)Ancillary Staff, Physician, or PAAncillary Staff, Physician, or PA
Past, Family, and Social History (PFSH) Ancillary Staff, Physician, or PAAncillary Staff, Physician, or PA
Vital SignsAncillary Staff, Physician, or PAAncillary Staff, Physician, or PA
History of Present Illness (HPI)Ancillary Staff, Physician, or PAAncillary Staff, Physician, or PA
X-Ray / Image Interpretation PhysicianPhysician
Physical Exam PhysicianPhysician or PA
Plan of Care PhysicianPhysician or PA (if continuing same plan of care)
Procedure PhysicianPhysician or PA

Thank You in Advance! 🙂
Kim
 
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Anyone, including a scribe, can document any of those items. It is the determination of the result of the item that is in question. It may be semantics, but I think it's an important distinction.
 

thomas7331

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I think the terminology you're using here is likely to be more confusing that helpful. To start with, CMS does not give 'permission' to anyone to document or not, so I think the use of this term is misleading. I've put the link to the most recent guidance on this below, and would recommend using the CMS wording as is. The intent of the guidance is not to say who may or may not document, but rather to emphasize that physicians are not required to personally document these sections themselves as long as the record reflects that they reviewed and supplemented the information as necessary.

Also, as noted in the post above, in the situation where ancillary staff are acting as a scribe, they may also document any section of the note as well, of course with the caveat that this is done appropriately.

In addition, you're distinction between Physician and PA in the documentation for new and established patients would apply only to situations where the PA is billing 'incident to' the physician. A PA (in every state that I know of) may evaluate and treat new patients and establish plans of care, and may document their services the same as would a physician, but in those situations are required to bill the services under their own credentials and not 'incident to' the physician's. It would be incorrect to state that a PA does not have 'permission' to document anything in particular, unless perhaps the physician who employs them has requested this.

 
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KStaten

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Anyone, including a scribe, can document any of those items. It is the determination of the result of the item that is in question. It may be semantics, but I think it's an important distinction.
Thank you, Sharon! :) You are correct... I should have noted that a scribe may document any of those sections, but clarified that it is per direction of for whomever they are documenting. I apologize for the confusion, as I should have specified that I am trying to do an overview of to whom may supply the information for the documentation, rather than who may physically/actively perform the documentation. Also, this, of course, as noted in my post, is strictly regarding which sections for which the doctor must supply the information in order for to correctly bill under the doctor.

However, it is to my understanding that if a scribe documents for a physician, then the documentation is still considered the physician's own documentation. The scribe is not allowed to alter -- neither add nor subtract-- any of the information being relayed. It would be similar to as if a doctor used a voice recognition program like Dragon® . (As a tangential soapbox rant, I have to add that Dragon® is no comparison to scribes, in terms of quality. We LOVE our scribes, as they are VERY valuable members of our team!❤ Boo on Dragon®!)

Also, if the ancillary staff or PAs are documenting per direction of the physician, then they, at that point, are acting as scribes, for which the same rules apply. (?) Is this correct or am I completely confused? Thank you!
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As an update, after reading another post, I see part of the confusion in my wording. So, yes, I would like to confirm that you are correct in that each member may document any of the sections. However, I was referring to which member may document and have that documentation recognized as counting towards the E/M level of service being billed when billing under the doctor. Again, I apologize for any confusion and appreciate your help!

Thank you! :)
Kim
 
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KStaten

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I think the terminology you're using here is likely to be more confusing that helpful. To start with, CMS does not give 'permission' to anyone to document or not, so I think the use of this term is misleading. I've put the link to the most recent guidance on this below, and would recommend using the CMS wording as is. The intent of the guidance is not to say who may or may not document, but rather to emphasize that physicians are not required to personally document these sections themselves as long as the record reflects that they reviewed and supplemented the information as necessary.

Also, as noted in the post above, in the situation where ancillary staff are acting as a scribe, they may also document any section of the note as well, of course with the caveat that this is done appropriately.

In addition, you're distinction between Physician and PA in the documentation for new and established patients would apply only to situations where the PA is billing 'incident to' the physician. A PA (in every state that I know of) may evaluate and treat new patients and establish plans of care, and may document their services the same as would a physician, but in those situations are required to bill the services under their own credentials and not 'incident to' the physician's. It would be incorrect to state that a PA does not have 'permission' to document anything in particular, unless perhaps the physician who employs them has requested this.

Thank you, Thomas7331! Oh goodness! I sincerely apologize for the confusing/ misleading terms. ☹ I think my brain is often "wired differently" and I often overthink (which is more often than not, a bad combination) and for this I apologize. Articles I've read often use the phrases "may or may not," "can or cannot," or "allowed or not allowed," so I simplified this in my head to "permission," when I drafted the table for lack of a better term at the time. :) I can see how that could sound misleading. I understand that Medicare will technically allow staff to document in the other sections... but, in certain sections, that would be designated as additional or supplemental information and is not recognized in terms of counting towards the E/M level of service being billed. I should have specified that I was referring to what documentation is recognized in each section to actually count towards the E/M level of service. For example, Medicare states that ancillary staff may now document the HPI and have that count towards the E/M level of service, but they may not, for instance, document the exam or plan and have that count towards the E/M level of service. Correct? 🤔

I should have also emphasized more clearly the distinction with incident-to billing. I stated in the original post, "...in order to correctly bill under the physician, what components must he or she document him/herself?" However, I agree that I should have emphasized that more clearly in order to reduce confusion.

Thank you for keeping me on track!:)
Kim
 

thomas7331

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No need to apologize! :) I think you have a good understanding of the requirements here from the coding and billing perspective. I'm only recommending caution in how you present that information to providers and staff, based on my own experiences. Providers and office managers are up against requirements and demands coming from a lot of different directions - state and federal regulations, licensing and certification limitations, malpractice, contracts, business needs, etc. So when you present coding requirements, I think it's helpful for providers to understand that you're coming from a perspective of what you as a coder are looking for in documentation in order to accomplish certain things. So, for example: in order to bill under the MD, we need a, b, c; in order to give full credit for the history, we need x, y, z; in order to protect against negative audit findings, it's best to document these things; and so forth. From a number of years of unfortunately having to learn things the hard way, I've just found that when coders present information to providers as 'you're not allowed to...' or you 'must' do certain things, it can create both confusion and sometimes resentment too because providers often feel that it's not within the coder's scope to tell them how to do their job. And to a certain extent, they are right about that. Hope this helps some!
 

KStaten

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No need to apologize! :) I think you have a good understanding of the requirements here from the coding and billing perspective. I'm only recommending caution in how you present that information to providers and staff, based on my own experiences. Providers and office managers are up against requirements and demands coming from a lot of different directions - state and federal regulations, licensing and certification limitations, malpractice, contracts, business needs, etc. So when you present coding requirements, I think it's helpful for providers to understand that you're coming from a perspective of what you as a coder are looking for in documentation in order to accomplish certain things. So, for example: in order to bill under the MD, we need a, b, c; in order to give full credit for the history, we need x, y, z; in order to protect against negative audit findings, it's best to document these things; and so forth. From a number of years of unfortunately having to learn things the hard way, I've just found that when coders present information to providers as 'you're not allowed to...' or you 'must' do certain things, it can create both confusion and sometimes resentment too because providers often feel that it's not within the coder's scope to tell them how to do their job. And to a certain extent, they are right about that. Hope this helps some!
Thanks again! That is helpful advice and good to point out. :) I agree that providers and office managers are often hit from all angles with information AND, unfortunately, misinformation-- and I certainly don't want to contribute to the latter of those two. ;) The fact that rules / policies are forever-changing (or so it seems) doesn't help either. And, I agree that understanding each person's position also helps tremendously and reduces frustration.
 
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