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Documentation for teaching Doctors

randiroyder

Networker
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86
Location
Dallas, Texas
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I am in a teaching hospital. My doctors will put in their notes "I agree with the documentation and assessment and plan by the resident team". When I am auditing his charts can I count that as part of his documentation for the charge level? Also on an H&P he states, "see Dr. ____ for the PFSH". Can I use that documentation also for the charge level?
__________________
 
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4,466
Location
Milwaukee WI
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Gov't payors vs commercial

If it's a government payor .. the teaching physician must indicate personal presence and participation in the HPI, exam and MDM. The statement you provided is not sufficient (if that's all the attestation your TP uses)

For the PFSH and ROS ... yes your teaching physician can refer to someone else's work (probably a resident) ... BUT ... s/he should be indicating the exact date and location of the referenced material and that s/he has actually reviewed this info. For example: "For PFSH and ROS please see Dr Resident's note of mm/dd/yy, which I have reviewed."

If it's a commercial payor, the resident's statement that s/he discussed the case with the teaching physician is sufficient, along with the counter signature and statement you provided as an example.

F Tessa Bartels, CPC, CPC-E/M
 
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