Wiki Split shared service

[rajesh.patel]

My NP and I both see the patient in Hospital follow up visit:

Is this attestation is valid:
"I was personally present throughout this encounter. I personally interviewed the patient regarding history and
review of systems. I personally performed a physical exam on the patient. I contributed to the medical decision
making of this encounter by reviewing / formulating the assessment and the plan for treatment and expected
outcome. I have reviewed and agree with the NPPs documentation and recommend no changes."

Signed by Me
and bill under MD

Thanks in advance

 

[jkyles]

Hi there, here is Medicare's rule for documentation:

E. Medical Record Documentation
Documentation in the medical record must identify the physician and NPP who performed the visit. The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.

I interpret this to mean each practitioner should fully document their portion(s) of the visit and clearly identify their work. Note that the person who signs the record will be whoever did the substantive portion.

I do not see an attestation requirement.

 

[csperoni]

I interpret that attestation to say MD performed history, MD performed exam, and MD and NP together did MDM.
That would allow you (for 2021 at least) to use either history or exam as the substantive portion.
Don't forget your FS modifier.
If you will be doing this regularly, I would suggest re-wording the attestation to not leave it open to interpretation, and make it clearer that the MD alone performed particular elements.