What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an evaluation and management (E/M) encounter?

Answer
Ancillary staff may document:

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Review of systems (ROS)
• Past, family and social history (PFSH)
• Vital signs

According to the 2019 Physician Fee Schedule (PFS), the final rule expanded current policy for office, and outpatient E/M visits. The guideline provides that any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner. Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that he or she has done so.

Resource: CMS Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQs) Physician Fee Schedule (PFS) (PDF, 46 KB).