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Physician Documentation

  1. #1
    Default Physician Documentation
    Medical Coding Books
    Hello everyone,

    I have a physician who documents "patient seen and examined. Agree with plan." There is a signature. However, this is the extent of his note - nothing more. In most cases, the plan is written by a resident of that specialty. Is that enough documentation to support the teaching physician presence and/or link the residents note?

    I have read CMS guidelines & I am still unsure.

    Any insight would be appreciated.


  2. #2
    It is not enough, that much I can tell you. I am not an expert in Teaching physician guidelines, but I can tell you that the "seen and agreed is nt sufficient for sure, that much I do know. You want to research Teaching Physician Guidelines in CMS to show your doctor that what he/she is doing is not sufficient. I am surprised your compliance department is not picking up on it. I will research some more, or perhaps someone else on the forums will chime in with the exact wording the teaching physician must include. And we will both learn

  3. Smile
    No that is not acceptable documentation. Here are a few examples of acceptable and non acceptable forms of documentation. Hope this helps..

    Acceptable forms:

    “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care.”

    “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note.”

    : “I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note.”

    Unacceptable forms:

    Agree with above.”, followed by legible countersignature or identity;

    “Rounded, Reviewed, Agree.”, followed by legible countersignature or identity;

    “Discussed with resident. Agree.”, followed by legible countersignature or identity;

    “Seen and agree.”, followed by legible countersignature or identity;

    “Patient seen and evaluated.”, followed by legible countersignature or identity; and

    A legible countersignature or identity alone

  4. #4
    Milwaukee WI
    Default Medicare vs T-19 vs commercial
    lrhoward has great examples ... if your payor is Medicare (or Medicaid in some states)

    Please note that while "seen and agree" is totally UNacceptable for Medicare to pay, commercial carriers are less restrictive and only require "supervision."

    And Medicaid varies by state and by whether it is "straight" or an AFDC HMO.

    So whether a service is billable based on the attestation statement depends on who is paying for the service.

    We always educate our physicians to the highest standard (Medicare's rules), but you should know that different carriers have different rules.

    F Tessa Bartels, CPC, CPC-E/M
    Last edited by FTessaBartels; 12-17-2008 at 12:48 PM.

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