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ROS and PFSH by ancillary staff

  1. #1
    Default ROS and PFSH by ancillary staff
    Medical Coding Books
    I read in my auditing book that if ancillary staff gather the ROS and past medical, family, and surgical history, or if this information was carried forward by the medical assistant from a previous visit in an electronic medical system, the provider must make a notation that they reviewed and/or updated this information. A provider at my clinic is stating that by signing the note, the provider is confirming that all of the information contained within the note has been reviewed and verified by them. Is it true that a signature is all that is required? Or does an auditor require a statement that the provider reviewed the information that was either pulled forward from a previous visit by the medical assistant or gathered at that visit by the medical assistant?
    Thank you very much for any help with this.

  2. #2
    The following excerpt is from CMS' '95 Documentation Guidelines for E/M Services:

    "DG: 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 a notation supplementing or confirming the information recorded by others".

    Therefore, simply signing the MR is insufficient. Thank you.
    Judy A. Haroon, RN, BSN, CPC, CGSC

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