Bernadette10
Guru
Patient was admitted to observation by the resident on 4/4 at 6 p.m. and documents a detailed history, comprehensive exam and moderate MDM. The attending adds this attestation:
"I have reviewed the resident's documentation, the patient's medical history, the resident's findings on physical examination, the patient's diagnosis, and the treatment plan as developed by the resident. I have discussed this case with the resident. I attest that I did not have any responsibilities other than the supervision of residents at the time this service was provided by the resident. I attest the care provided by the resident was reasonable and necessary."
Both the resident and attending see the patient the next day on 4/5 at both 8 a.m. and 8 p.m. and document notes with an EPF history, comprehensive exam and moderate MDM, and the patient is discharged.
What is billed? Since the attending's attestation on the initial note only says the resident's care was reasonable and necessary but doesn't say he agreed with the findings in the note, this note can't be used, can it?
If so, that means only the 2 notes from 4/5 can be used, and would mean 99234-236 could be billed, but there's not at least a detailed history on either note. So is the only option to bill subsequent observation care 99225?
Or is the attestation from the 4/4 note enough to allow that note to be used to bill 99218 for 4/4 and 99217 for 4/5?
"I have reviewed the resident's documentation, the patient's medical history, the resident's findings on physical examination, the patient's diagnosis, and the treatment plan as developed by the resident. I have discussed this case with the resident. I attest that I did not have any responsibilities other than the supervision of residents at the time this service was provided by the resident. I attest the care provided by the resident was reasonable and necessary."
Both the resident and attending see the patient the next day on 4/5 at both 8 a.m. and 8 p.m. and document notes with an EPF history, comprehensive exam and moderate MDM, and the patient is discharged.
What is billed? Since the attending's attestation on the initial note only says the resident's care was reasonable and necessary but doesn't say he agreed with the findings in the note, this note can't be used, can it?
If so, that means only the 2 notes from 4/5 can be used, and would mean 99234-236 could be billed, but there's not at least a detailed history on either note. So is the only option to bill subsequent observation care 99225?
Or is the attestation from the 4/4 note enough to allow that note to be used to bill 99218 for 4/4 and 99217 for 4/5?