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Exam question


Best answers
I need some memory help! Can the physician assistant dictate the exam portion of the visit and the physician just make a statement that he concurs with it and point out pertinent findings if any or does the physician have to dictate the whole exam?



Rockledge, FL
Best answers
According to the CMS the notation "seen and agree" or simply countersigning is not sufficient. He/she must specifically document what he/she has personally done. The definition of a split/shared visit according to CMS is a medically necessary encounter with a patient, where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face to face with the same patient on the same date of service. This can be found in the Medicare claims processing manual Pub 100-4, chapter 12, section 30.6.1-.13 An article came out on lamedicare.com about incident-to and split/shared visits. You should check it out...Lynn