I know this is my Medicare carrier but maybe this will help?
Jurisdiction 11 Part B
What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an evaluation and management (E/M) encounter? Can ancillary staff act as a scribe for a provider?
Ancillary staff may only document:
Review of systems (ROS)
Past, family and social history (PFSH)
These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.
Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.
Scribe (E/M Services):
If ancillary staff is present while the physician is gathering further information related to the HPI or any of the three key components, he/she may document (scribe) what is dictated and performed by the physician or NPP. The physician needs to review the information as it is written, documented, recorded or scribed and write a notation that he/she reviewed it for accuracy, add to it if supplemental information is needed and sign his/her name. The name of the scribe must be identified in the medical records.
Ancillary staff does not need to be employed by the physician (example - hospital employees).
CMS 1995 & 1997 E/M Guidelines
last updated on 10/04/2011
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