Wiki 2 questions - teaching hospitals

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alices

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I am sorry but I have 2 questions hope someone can answer both,,
1) teaching hospitals, if a resident sees a pt completes the ER chart what is it that the attending physician has to do, we have a policy here that they have to stamp and sign the chart saying that they seen and concur with the resident, we had one dr send back our chart refusing to sign saying he didn't examine the pt do they need to examine the pt as well being there supervising the resident?

2) for attempted procedures are they codeable? example dr says attempted to reduce shoulder dislocation but unsuccessful, or I performed an i&d but no pus was expressed are they codeable/billable and if not is there somewhere I can get this in writing I have tried mcare website but I could not find anything, i could have been looking in the wrong place I don't know.
I hope someone can answer both these questions because I really need help on this I do not want to do it wrong...thank you alice
 
Hi Alice,

http://www.acep.org/Content.aspx?id=30500 This link includes Teaching Physician Guidelines FAQ from the ACEP site. The ACEP site is a great reference for ED coding. For further info: http://www.acep.org/reimbursement/

Yes, completed procedures can be billed even if unsuccessful. Physician's knowledge, skill and risk still exist. The documentation will determine if you need to append modifier -52 for reduced services or -53 for a discontinued procedure. Some ED providers do not want to charge for unsuccessful procedures or will not bill if the procedure will be repeated by a specialist on the same date. Check your in-house policy.
 
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