Question Doctor vs. ancillary staff

akfrog224

New
Messages
3
Best answers
0
Hello,

I have a question regarding documentation responsibilities.

Here is the situation: a patient is seen for massage therapy, ultrasound therapy, routine injections, lab draws ect. by ancillary staff (medical assistant, massage therapist, lab tech, imaging tech) clinical documentation is entered by the staff member who performed/provided the service. Is it the supervising providers responsibility to review the documentation and finalize/lock the note so that it reads "electronically signed and locked by Dr. Sally"? if they are the billing/rendering provider?

My instincts are telling me if the doctor is the billing/rendering provider then it is their responsibility to review and finalize the clinical note. I am unable to locate any policies/procedures on this and have a provider saying they dont have to review or lock a note when the services were performed by ancillary staff (a medical assistant, or imaging tech).

Please advise.
Thank you in advance.
MP
 

thomas7331

True Blue
Messages
2,139
Best answers
3
No, there is no requirement that a physician review and sign every piece of documentation created by their clinical staff. In large practices, that would create an enormous and unnecessary documentation burden on physicians for a task that does not really accomplish anything since the physician is not the one who actually performed the service. Staff must always perform their work 'incident to' a physician's plan of care, but adding a signature does not help to meet those requirements.

The scope of practice and the level of supervision required for clinical staff is governed by state law, and while physicians are responsible for taking measures to ensure that their staff are practicing safely and competently, there are no states, to my knowledge, that require the physician the review and sign every note.
 

akfrog224

New
Messages
3
Best answers
0
Thank you. We have recently received a denial from BCBS stating: "determined this procedure wasn't performed by billing provider". Would you be willing to share supporting appeal verbiage based off your previous reply?
 

thomas7331

True Blue
Messages
2,139
Best answers
3
Thank you. We have recently received a denial from BCBS stating: "determined this procedure wasn't performed by billing provider". Would you be willing to share supporting appeal verbiage based off your previous reply?
I can try, but can you give a little more detail? What was the procedure and the circumstances of the denial?
 

akfrog224

New
Messages
3
Best answers
0
Certainly. One example is the patient rec'd 97124 x 4 units. The note was completed by the massage therapist and locked by the massage therapist. Services were denied stating: "procedure wasn't performed by billing provider." The claim was submitted with the group NPI as the billing and the supervising physician NPI as the rendering.
 
Top