For an evaluation & management visit, the doctor is responsible for certain parts of that visit, I have heard. So does Medicare state this openly?
Well, in the evaluation and management service documentation guidelines, the agency states that ancillary staff or even the patient (via questionnaire) may record the review of systems (ROS) and past, family, and/ or social history (PFSH) portions of the history component.
Watch out: To get credit for these history elements, your doctor should date and sign the patient's chart to point to the fact that he reviewed the whole history note.
Source: According to the 1995 evaluation and management guidelines, "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. In order to document that the doctor reviewed the information, there must be a notation supplementing or corroborating the information recorded by others."
As a matter of fact, the 1997 guidelines include the same wording as the 1995 Evaluation & management guidelines. What's more, the 1997 guidelines refer to documentation by ancillary staff in yet another section, which describes requirements for the "constitutional" element of the exam: Measurements of any three of the following s even key signs: Sitting or standing blood pressure, supine blood pressure, pulse rate and regularity, respiration, temperature, height, weight.
Word of caution: You should take a look at your state requirements. For example, some states require the physician to sign off on any incident-to services, say for instance 99211 as well as higher-level E/M services such as 99212-99215, provided by mid-level providers. Other states don't require the physician to sign off on incident-to services, however the physician does have to create the plan of care.
For more on this and for other Medicare reimbursement updates, sign up for a one-stop medical coding guide like Supercoder.com.
Watch out: To get credit for these history elements, your doctor should date and sign the patient's chart to point to the fact that he reviewed the whole history note.
Source: According to the 1995 evaluation and management guidelines, "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. In order to document that the doctor reviewed the information, there must be a notation supplementing or corroborating the information recorded by others."
As a matter of fact, the 1997 guidelines include the same wording as the 1995 Evaluation & management guidelines. What's more, the 1997 guidelines refer to documentation by ancillary staff in yet another section, which describes requirements for the "constitutional" element of the exam: Measurements of any three of the following s even key signs: Sitting or standing blood pressure, supine blood pressure, pulse rate and regularity, respiration, temperature, height, weight.
Word of caution: You should take a look at your state requirements. For example, some states require the physician to sign off on any incident-to services, say for instance 99211 as well as higher-level E/M services such as 99212-99215, provided by mid-level providers. Other states don't require the physician to sign off on incident-to services, however the physician does have to create the plan of care.
For more on this and for other Medicare reimbursement updates, sign up for a one-stop medical coding guide like Supercoder.com.
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