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E/M elements

  1. #1
    Default E/M elements
    Medical Coding Books
    I am having another brain cramp today. Can someone help me out? Can't the nurse document the PFSH and the ROS for the E/M?

  2. #2
    Location
    North Carolina
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    3,126
    Default
    Yep

    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.


    http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp

    Page 8 on the 97 DG's

    It's the HPI that can not be delegated to the ancillary staff

  3. #3
    Default
    Thanks Rebecca, you're the best!!

    Happy Holidays

  4. #4
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    North Carolina
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    Same to you!!

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