Part B Insider (Multispecialty) Coding Alert

Published on Sun Jan 20, 2008 PDF

Make sure the physician signs the note, rather than stamping a standard line

Rubber stamps can be a great time-saver to stamp a file -paid- or to stamp your practice's name on a patient's check--but not when it comes to a physician's documentation.

In many instances, the physician will have residents or other providers assist them in their hospital rounds. The physician will then review the note and indicate whether he or she agrees with the documentation.

Here's the quandary: Rather than re-writing the entire note, some physicians simply carry a stamp that states, -Seen and Agreed,- which they place below the other pro-vider's documentation. 

-I just returned from talking at the AAPC conference in Anaheim where this was discussed,- says Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for UPMC, University of Pittsburgh department of surgery. -Although it was not written officially, I was on a conference call with CMS when the new guidelines for teaching physicians were introduced. Someone asked this very question, and their answer was plainly, -No.- Others in the group at the conference this week also confirmed that they heard this, too.-

-This is not a recommended practice, from the simple standpoint of who has access to the stamp and when is it being stamped,- she adds. -Also, the stamp -seen and agree- doesn't satisfy the teaching physician guidelines for a proper teaching physician attestation.-

Even if the nonphysician practitioner is -scribing,- -the answer is still no,- says Quinten A. Buechner, MS, MDiv, ACS-FP/GI/PES, CPC, CCP, CMSCS, president of Pro-Active Consultants, LLC. -For -scribing,- the scribe must identify themselves, document that they are only writing what the physician dictates, and then they both sign off. -Seen and agreed- does not work for any legitimate billing of any service,- he says.

According to CMS- Internet-Only Manual (IOM) Section 100-04, 12, 100, -Seen and agree,- followed by legible countersignature or identity, is an example of unacceptable documentation.

Better way: Your documentation might read, -I have interviewed and examined the patient with Dr. Resident. I have personally confirmed the key elements of the history and physical examination and have personally reviewed the radiographic and laboratory data that are available. I have collaborated directly with Dr. Resident in the formulation of the assessment and plan. I have edited the above note in electronic format, and the content reflects my personal involvement in this patient encounter,- advises Associated Specialists in Medicine in St. Louis.