E/M documentation

todd5400

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Refreshen my memory please. The doctor dictates the CC, HPI, and MDM. The PA dictates the ROS and PFSH. Who dictates the exam when billing incident to? Can the PA dictate the exam and the doctor sign off?
Thanks
Mary
 
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The doctor dictates the CC, HPI, and MDM. The PA dictates the ROS and PFSH. Who dictates the exam when billing incident to? Can the PA dictate the exam and the doctor sign off?
Thanks
Mary

Mary,
A counter signature is not sufficient to show that incident-to requirements are met.

Here is a great incident-to article that explains the documentation requirements:

http://www.lamedicare.com/provider/viewarticle.aspx?pf=yes&articleid=5130
 
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