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Physician's and residents

  1. #11
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    Medical Coding Books
    We bill for our supervising physicians who see patients with residents and have pre-loaded attestations in our EMR. Here's an example of what may go on the bottom of the resident's note:

    I saw the patient on 2/15/10, performed psychiatric evaluation with psychiatry resident, Dr. X, and discussed case with her. I reviewed her note and agree with the documented findings and plan of care. For details of evaluation and plan of care see her note.

    Prior to EMR, we did have a pre-printed statement on our paper notes.

    Hope that's helpful.
    Donna E. Young, CPC

  2. #12
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    According to the medicare guidelines it was ok to have it within the EMR but i wasn't sure about pre printed. I have spoken to a few people who say they have a pre printed form also and they check with their local carriers first but unfortunetly i haven't recieved feed back from ours. Would you mind telling me what state your in ?? We are in Louisiana. Thank you soo much for replying, we are trying to get as much feedback as possible. We would also like to contact other carrier's to see if they can provide us with documentation stating they except this so that we have something to show our medicare rep's.

  3. #13
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    Quote Originally Posted by FTessaBartels View Post
    There are a couple of different forms; here are two attestation statements that are pre-printed on forms used at our hospital:

    I have seen and examined this patient on rounds with the surgical residents and/or PAs, reviewed the pertinent diagnostic data and agree with what is written above. My assessment and plan of management has been discussed with the surgical residents and PAs, and is reflected in this history and physicial examination/consultation. (followed by area for Attending Physician Signature and Date/time)


    History reviewed, patient examined, discussed with Intern/Resident. Agree with assessment and plan as written. See additional note in progress section. (Followed by area for Attending Physician signature and Date/Time)

    NOTE - Our attendings typically dictate an H&P or Consultation note in addition to what is written on the form by the resident. That dictation usually refers back to the resident's documentation for ROS and PFSH.

    RE STAMPS - I would stay away from stamps. As you have discovered the carriers really don't like them.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Would you mind telling me your local carrier also ?? Like i metioned before we are trying to contact as many carrier's as possible to see if they have documentation on weather or not they accept this and if so then at least we have something to show our med rep. Thank you

  4. #14
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    I am in Hawaii. Our carrier used to be Noridian and now it is Palmetto. I don't know if our local carriers were ever asked about the pre-printed paper note (these were used prior to me working here) but we work within a hospital so I would think if it had been a problem the hospital wouldn't have allowed us to use them. Good luck, I know it's terribly frustrating trying to get answers from the carriers.
    Donna E. Young, CPC

  5. #15
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    Yes and this is something our docs would like pre printed on our forms and it has to be approved so before we can say "hey add this" we have to show proof or something as to why we want this and make sure it is ok before we do it. I think our local carrier is pinnacle but they were having a fued over wheather it would be trailblazer or pinnacle.

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