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Beware, Nurse's History Note Might Be Audit Bait
Do you let your nurses do the doctor's work? If yes, this is something you should avoid doing because on doing so, you could wind up with a non-payable visit. According to FAQ answer from Palmetto GBA, a Part B carrier, the only parts of the E/M visit that an RN can document independently are the Review of Systems, Past, Family, and Social History and Vital Signs. The doctor or mid-level provider must review those three areas and write a statement that the documentation is correct or add to it. Only the physician or non-physician practitioner who conducts the E/M service can carry out the History of Present Illness (HPI).
There are exceptions: In some instances, an office or Emergency Department triage nurse can document 'pertinent information' pertaining to the chief compliant or HPI. However, you should treat those notes as 'preliminary information'. The physician providing the E/M service must document that he or she explored the HPI in more detail. Other payers have expanded on this, letting physicians know that they can't simply initial the nurse's documentation.
The good news is that because of this clarification, your dermatologist will not be able to repeat the triage nurse's work. At present, if the nurse writes "skin rash x 4 days" at the top of the note, some auditors might insist that your physician needs to write "skin rash x 4 days" in his own handwriting underneath. However, that requirement is a thing of the past if your carrier echoes Palmetto's requirement.
Bad news: Now this carrier has made it clear that your doctor cannot get credit for HPI until and unless he elaborates on what the triage nurse wrote. In the above instance, the doctor needs to note more information about the patient's four-day skin rash for the entry to count in HPI.
Everyone does not welcome the Palmetto FAQ with open arms. The clarification may cause more confusion as there is no definition of the word 'preliminary'. Palmetto doesn't explain how much extra documentation could be required to comply with the guidelines.
For more on this and other medical coding updates, stay tuned to a medical coding guide like Supercoder!
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