Who can document the Exam elements in an Ophthalmology practice? Is it strictly the MD/OD or can the C.O.T. (tech) document and have them be counted as exam elements to establish the E/M level that is being billed?

I am in the process of starting a chart audit in the practice I work at and am getting some pushback in regards to the above issue. In the physician auditing workbook that I have used in past practices, I find the following information: Only the billing provider may document the chief complaint and the HPI components of the history. Ancillary staff may not document the HPI and have that history count as part of the documentation in support of the service level in auditing the note. Where is this written? The Documentation Guidelines explicitly state that ancillary staff may record the ROS and PFSH. CPT Assistant has also stated this.” (Excerpted from pg 47 Physician Auditing Workbook, Decision Health 2010)

My interpretation of this means that the exam elements documented by the tech are not able to be used in the overall count of items for a comprehensive eye examination. Does anyone have any insight onto this issue?

Any help would be creatly appreciated. Thanks.