Part B Insider (Multispecialty) Coding Alert

Published on Tue May 10, 2011 PDF

Question: Our physician works with residents every year and it is very time-consuming for him. He does review their documentation and indicate that he agrees with their findings. He doesn't use a rubber stamp -- instead he actually writes, "Seen and agreed" on the chart before he signs it. A consultant told us that this is unacceptable. Why would that be?

Answer: The consultant is correct. Although you've accurately noted that a rubber stamp stating "Seen and agreed"is not acceptable, neither is a handwritten notation with the same phrase, CMS says.

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

Other examples of unacceptable documentation in this scenario include, "Rounded, reviewed, agree," and "Discussed with resident. Agree," the IOM indicates.

Better way: Your documentation might read, "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs," according to the IOM.

To read the IOM's take on stamped signatures, visit the CMS Web site at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.