Exam & Diagnosis documenting in E/M

In the CMS E/M Documentation Guidelines it mentions that the CC, ROS,& PFSH can be recorded by ancillary staff of the patient but it does not tell us who can perform the Exam and MDM component. I have been asked by an RN if there are any guidelines that states the RN or ancillary staff cannot document in these areas. She is not wanting to document the treatment plan but she is wondering why she could not do some of the elements of the Exam above and beyond the vital signs and why she cannot provide diagnoses in the MDM for the patients that are being seen for their chronic conditions that were previously diagnosed by the provider. Her reasoning is she can't find anywhere that it says she can't do this and ultimately the provider would be reviewing her documentation and signing off on the note.

Does anyone know of a reliable resource I can view that says who can or cannot perform the Exam and MDM?

Thanks!

re: Exam & Diagnosis documenting in E/M

You've answered your own question: the Documentation Guidelines say what the RN can do. They cannot do any other part.

EXAM and MDM are out of their scope of practice for physician services (not for nursing services, I don't mean to imply that. RNs do exams and exercise complex MDM while doing their jobs.)

Look at the description of 99211: that is the only E/M service that "may not require physician presence"

download the OIG report from this article:

http://codapedia.com/article_431_OIG-Report-on-Incident-to-Billing.cfm