compliance/audit issue

[kumeena]

I neeed everybody's feed back on this issue.In a teaching hospital setting resident writes notes and his diagnosis then Attending writes " I review the
HPI, Exam and diagnosis with resident", then he writes his findings and writes different diagnosis.

As per my knowledge if the attending doesn't write I agree/concur with resident diagnosis/findings I should code with Attending diagnosis.

Please help

[SCanterbury]

If that's all he's writing then you've got a bigger problem than whose diagnoses to use.

The Teaching Physician note has to reflect that the TP performed or was present during the resident's performance of the key portions of the service. This is done via the TP note containing an explicit statement of TP presence face-to-face with the patient. Medicare gave many examples of sufficient TP notes, and they all began with "I saw the patient..." or "Patient seen with the resident..." or the like.

Based on the note you quoted, there is no indication that the TP made any face-to-face contact with the patient. They could have (and possibly did) only discuss the patient with the resident without setting foot in the room themselves.

Seth Canterbury, CPC, ACS-EM
Education Specialist
University of Florida Jacksonville Physicians, Inc.
Clinical Data Quality-Education Department
653 West Eight Street
Tower I, Suite 606
Jacksonville, FL 32209
(904) 244-9643

[LLovett]

I agree with Seth.

Based on your above note you do not have a billable service at all.

Laura, CPC, CEMC

[kumeena]

Thank you for your input.

[FTessaBartels]

Kumeena wrote: Attending writes " I review the HPI, Exam and diagnosis with resident", then he writes his findings and writes different diagnosis. (emphasis added by FTB)

I'd have to see the note to be certain ... but if the teaching physician documented his/her own findings you can use those elements to determine your level of service.

I do agree with the other posters that this attestation statement is inadequate by itself. The physician MUST indicate his/her presence and participation in the history, exam and MDM, and concurrence with the resident note (if that is the bulk of the documentation ... which it usually is).

HOWEVER .. if this is a commercial payer (NOT Medicare or Medicaid), this may still be a billable service. Most commercial payers allow the teaching physician to "supervise" by any means, including phone.

In any case, I would use the TP diagnosis over the resident diagnosis (assuming your documentation is billable).

Hope that helps.

F Tessa Bartels, CPC, CEMC

[kumeena]

Thank you Tessa

[smathis1]

The teaching physician does not have to personally see the patient if covered under the primary care exception. (Medicare Claims Processing Manual, Chapter 12, Sect. 100.1.1.C)
Your term "teaching physician hospital" sounds like it was an inpatient service (?), but if it was an office visit, the rules may be different because of the primary care exception.