Wiki Resident dictation


Kalamazoo MI
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I have residents dictating for the physicians for consults, H&P's and follow up days. The physicians are adding paragraphs stating "pt seen and agree with above", or nothing except their signature.
Do the residents fall under the same rule as split shared or incident to? i need clarification for the residents dictation.

Thank you
resident notes

Resident notes are not to be the same as split/shared or incident to notes. These are reserved for NPP's (non-physician providers like PA-C & ARNP's)

Each note written by a resident needs to be either:
- signed by a staff physician with a teaching statement indicating that they saw and examined the patient and have discussed the case with the resident and that they either agree with what the resident wrote and/or they add their own comments and then their signature. This is used if the physician had face to face time with the patient and is billing for the encounter.
-signed with just the staff physician's signature and no teaching statement would indicate that the staff physician did not have face to face time with the patient and they are not billing for the encounter.

I hope this helps to clear up your question.
Linda S. Reese, CPC,CPMA
Teaching Physician guidelinesa are different than Incident To rules. Teaching physicians must personally document their physical presence during critical or key portions of the visit and their participation in the management of the care of the patient. You will find scenarios and examples of Minimally Acceptable and Unacceptable documentation.

See 100-04 Medicare Claims Processing Manual, Chapter 12, Section 100 Teaching Physician Services
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Thank you very much for your help and timely response. I printed out information on residents doing dictation, but, you read and read and sometimes are more confused than you were before.
Modifier GC

Whenever a resident provides a service under the direction or supervision of the teaching physician, the physician should bill the services or the procedure along with the Modifier GC. Modifier GC indicates that the teaching physician was present when the services were performed by the resident.