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Thread: MA documenting

  1. #1
    Join Date
    Apr 2007
    Las Vegas

    Default MA documenting

    AAPC: Back to School
    We are currently having a debate in our office regarding this topic. The MA can only document the CC and take vitals, right? Isn't the doctor supposed to document everything else regarding the pt? If so, where can I find it in "black and white"?
    Malama pono,

    Sundae Yomes

  2. #2


    Check under the CMS website for evaluation and management documentation guidelines. You should find in the guidelines what the ancillary staff can document and what the physician should document.

  3. #3
    Join Date
    Apr 2007
    North Carolina



    I use '97 guidelines. Refer to page 6. ROS and PFSH can be recorded by ancillary staff. The provider needs to document that he reviewed the information.
    Last edited by RebeccaWoodward*; 05-02-2008 at 05:47 PM.

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