Questions for Dr. Stern
About Your Urgent Care Center
42. Can you tell me what guideline is being used for compliance when the physician signs off on the statement of "I certify that I have reviewed all of the data on all pages of this form, and I deem the exam clinically appropriate for this visit?" This question refers to the use of nursing documentation in the coding process whereby the nurse documents, for example, hypertension and the physician does not. What guideline allows the usage of the nursing documentation for coding purposes?
CMS has officially ruled that the Review of Systems and Past Medical History can be documented by the:
- Patient
- Ancillary staff, or
- The provider.
The provider must document that this information was reviewed. Per page 13355 of the Part B Answer Book:
“The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.”
CMS has not (nor has the AMA) made any specific ruling about who may document the HPI. The local Illinois Medicare carrier stated (just this year) that they want the HPI documented by the provider. At the very minimum, we would suggest that you require the provider to perform some documented interaction with the HPI. NOTE: CDH are free to divide the documentation duties between any of the staff (nurse, doc, PA, etc.) in any way you deem best for your organization.I hope this answers your questions. Feel free to call for clarification or with other questions.
