If it's a government payor .. the teaching physician must indicate personal presence and participation in the HPI, exam and MDM. The statement you provided is not sufficient (if that's all the attestation your TP uses)
For the PFSH and ROS ... yes your teaching physician can refer to someone else's work (probably a resident) ... BUT ... s/he should be indicating the exact date and location of the referenced material and that s/he has actually reviewed this info. For example: "For PFSH and ROS please see Dr Resident's note of mm/dd/yy, which I have reviewed."
If it's a commercial payor, the resident's statement that s/he discussed the case with the teaching physician is sufficient, along with the counter signature and statement you provided as an example.
F Tessa Bartels, CPC, CPC-E/M
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join