Wiki E & M documentation requirements

[Jlokloski]

I have a doctor that dictates his consults with a one line history of present illness and a very short plan and the P.A. does an extensive consult. Does the doctor need to dictate more extensive or can we base our code on the P.A. and the little the doctor dictated? The plan indicates a heart cath is planned. Also, in the office his dictation is very short. He does have the day sheet that he makes notes on and signs the bottom. How much of that can we use in conjunction with his dictated letter?

Thank you for your help.

 

[thomas7331]

If this takes place in a hospital, the MD and PA notes can be combined and billed as a split/shared service as long as the physician provides 'any face-to-face portion of the E/M encounter with the patient'. If it's in the office, then the 'incident to' rules would apply and the visit could only be billed under the MD if the PA is executing the MD's plan of care and not initiating or making changes to that plan. The CMS guidelines for both situations can be found in chapter 12 of the Medicare Claims Processing Manual, link here:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Hope this helps some.

 

[mitchellde]

You cannot do shared encounters for consults or new pAtients. In that instance you may bill for the Physician using only that part of the note , or the PA using their part of the note. Of neither note can support the qualifications of a new pYient or consult, then you have no visit.

 

[thomas7331]

You cannot do shared encounters for consults or new pAtients. In that instance you may bill for the Physician using only that part of the note , or the PA using their part of the note. Of neither note can support the qualifications of a new pYient or consult, then you have no visit.

Debra, could you please direct me to additional information on this? All of the guidelines I'm familiar with say that split/shared visits are allowed in a hospital inpatient, outpatient or ED setting - I've never come across anything stating that this is limited only to established patients. In the office setting I'd agree with you though.

 

[mitchellde]

The reference I have saved is CR 4215 which states you cannot share a consultation, and CR1776 indicates you cannot share a new patient. CR1776 has been retired and us no longer searchable.