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ED Coding and Reimbursement Alert

Reader Question:

Missing Chart Information

Published on Thu Mar 01, 2001

Question: As I reviewed a group of charts to code, I found that one physician had signed for another either for a physician no longer with the group or someone other than the provider who wrote the final diagnosis. How should I handle coding these charts?

Michigan Subscriber

Answer: It is common in the emergency department for two physicians to provide service, particularly at shift change. The physician who signs the chart, however, assumes legal responsibility for patient care. Therefore, the last physician to see, diagnose and discharge the patient is generally the physician of record for billing purposes. A situation in which someone other than the physician of record signs the chart and then bills for the service opens up potential legal as well as billing fraud risk.
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