Medical assistant seeing the patient


True Blue
Boca Raton, FL
Best answers
I have several questions regarding visits at which the patient sees only a medical assistant (for something that is allowed to be performed by auxiliary personnel, such injection or suture removal):

1. Does a licensed provider have to be present in the office?
2. Does a licensed provider have to sign the note?
3. Does the provider's plan or order for this service have to be documented in the patient's chart, or is a verbal statement sufficient (such as the provider telling his MA that the patient has to return for an injection on such-and-such a day, without actually documenting it in the chart)?
4. With regard to question 3, what if although it does not get documented in the chart, but does get written in the "return to office" section of superbill? (The superbills get saved, but not in the patient's chart, and they are not signed.)
5. In her note, can the MA enter the same diagnosis that the provider had used at the time he ordered this service, or would her entering a diagnosis be the equivalent of a non-licensed person making a diagnosis, and instead she should just use a Z code (such as Z48.02 - encounter for suture removal)?

Thanks for your input!