Wiki Copy and paste

[kathleenl]

Hi,
My scenario is this: I have physician who, when he sees and inpatient, has a fully credentialed Nurse practitioner see the patient first and they will document the whole note. The physician then copies and pastes that note making a change to the medications to be given, but not much more. Is that sufficient to bill under his name? I am a bit unclear as to how much a physician needs to add to be able to consider a note "theirs".
Any guidance is appreciated.
-Kathleen, CCS-P

 

[thomas7331]

I've pasted the CMS guidance on this below, which you can find in the Medicare Claims Processing Manual, Chapter 12. Basically the only requirement to bill under the physician's credentials is that they perform 'any face-to-face portion' of the visit. If they are copying and pasting everything except a change to the medication, then in my mind, that is not sufficient because that is not a record of a face-to-face service. The physician would need to document that they performed a separate history and/or exam of some kind to show that they also personally saw and evaluated the patient.

When a hospital inpatient...E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's UPIN/PIN.

 

[kathleenl]

I've pasted the CMS guidance on this below, which you can find in the Medicare Claims Processing Manual, Chapter 12. Basically the only requirement to bill under the physician's credentials is that they perform 'any face-to-face portion' of the visit. If they are copying and pasting everything except a change to the medication, then in my mind, that is not sufficient because that is not a record of a face-to-face service. The physician would need to document that they performed a separate history and/or exam of some kind to show that they also personally saw and evaluated the patient.

When a hospital inpatient...E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's UPIN/PIN.

Thanks! That was very helpful!
-Kathleen