Orthopedic Coding Alert

Documentation:
Avoid Making Your Nurse's History Note Into Audit Bait

The physician must indicate that he or she reviewed any nurse’s notes. Warning: Don’t let your nurses do the doctor’s work, or you could wind up with a non-payable visit. The only parts of the E/M visit that an RN can document independently are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to [...]