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Physician's and residents

  1. #1
    Default Physician's and residents
    Exam Training Packages
    When a patient is seen by a resident along with a physician the staff is supose to write documention showing his involvment. That part we understand. Our doctor's usually exam the patient after the resident and write something like " Patient seen and examined along with resident, agree with all residents findings" Or "Patient seen and examined along with resident, agree with resident's findings except for ____ " My question is, can we apply this statement to our actual medical record and have the doctor check it off wheather he was present or not and sign or does he have to physically write this statement each time. Also they want to know if they can make a stamp with this actual statement that way they just have to sign and make any changes to the findings. I know that CMS clearly states no stamp signatures but this wouldn't be a signature, it woud be an automatic statement that is on every progress note. Thank you in advanced.

  2. #2
    Default
    Now, I'm not positive but I would venture a guess of no way. I'm not even sure that the documentation that your teaching physician is doing is appropriate. I am taking some E&M courses right now and they state that the teaching physician has to provide the exam and make his own determinations. I think that he can state that he agrees with the student but he must still perform his own evaluations independant of the student. It doesn't mention a stamp for that use anywhere and I seriously doubt that they would allow it, but I could definitely be wrong.

    As I said, I am not completely sure about all of this but below I put the web address of a copy of the MLN matters for teachings physicians and documentation guidelines. Read it and maybe it covers these questions. Just my opinion, and I hope it helps

    http://www.cms.hhs.gov/MLNProducts/d...gresfctsht.pdf
    Last edited by LTibbetts; 01-26-2010 at 01:57 PM.

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Check with your carrier
    Some of these rules are carrier specific, so be sure to check with your carrier.

    There is a difference between residents and students. Residents have their MD and are licensed physicians, but are in a post-graduate training program. (Every year there are MDs who go into practice without completing a residency program.) Students have not yet completed their medical school training and do not have an MD. The only part of a student's documentation that can be used is the ROS and PFSH (which can be taken by anyone, even someone off the street).

    We are in a large teaching hospital. Many of our forms (e.g.H&P, Consults) have a pre-printed attestation statement that the teaching physician can check and then sign/date. This is considered acceptable documentation of physician presence and involvement when the originator of the document is a resident.

    This is really not much different than having templated information in an EMR that only requires a "click" to add an entire phrase.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Default
    Yes for student's the staff must personally perform the exam and ros but for resident's the staff can refer to the note. I have several article's refering to teaching facilities and the one we refer to the most states " Following are minimally acceptable documentation for each of these senarios- I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the residen'ts note. I saw the patient with the resident and agree with the resident's findings and plan" The teaching physician's must document he personally saw the patient, personally performed key portions or critical portions of the service and participated in the management of the patient. They just want to make this note a part of the medical record and be able to check off and make any notation's along with their signature. Thanks again

  5. #5
    Default
    Quote Originally Posted by FTessaBartels View Post
    Some of these rules are carrier specific, so be sure to check with your carrier.

    There is a difference between residents and students. Residents have their MD and are licensed physicians, but are in a post-graduate training program. (Every year there are MDs who go into practice without completing a residency program.) Students have not yet completed their medical school training and do not have an MD. The only part of a student's documentation that can be used is the ROS and PFSH (which can be taken by anyone, even someone off the street).

    We are in a large teaching hospital. Many of our forms (e.g.H&P, Consults) have a pre-printed attestation statement that the teaching physician can check and then sign/date. This is considered acceptable documentation of physician presence and involvement when the originator of the document is a resident.

    This is really not much different than having templated information in an EMR that only requires a "click" to add an entire phrase.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Yes that's exactly what they want, a pre-printed attestation statement that the teaching physician can check and then sign/date or a stamp. We have kinda gotten the run around from our local carrier's. When we say stamp they think signature, when we try to explain they get confused, for the most part we are hearing yes as long as they sign and date with a notation. Would you mind sending me a blank copy of your H&P form so i can show them ? Or could you tell me what your statement says. I would really appreciate it. Thanks

  6. #6
    Default
    Quote Originally Posted by cpccoder2008 View Post
    Yes for student's the staff must personally perform the exam and ros but for resident's the staff can refer to the note. I have several article's refering to teaching facilities and the one we refer to the most states " Following are minimally acceptable documentation for each of these senarios- I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the residen'ts note. I saw the patient with the resident and agree with the resident's findings and plan" The teaching physician's must document he personally saw the patient, personally performed key portions or critical portions of the service and participated in the management of the patient. They just want to make this note a part of the medical record and be able to check off and make any notation's along with their signature. Thanks again
    Sorry, the students can perform the ROS and PFSH, the exam has to be performed by the staff, we don't have student's in the area i code only resident's, so i wasn't sure.

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default Attestation statements
    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
    Last edited by FTessaBartels; 01-26-2010 at 03:32 PM.

  8. #8
    Default
    Thank you, i will check with our carrier to see if these are acceptable in our area, thank you again

  9. #9
    Default No reply
    I have contacted our local carrier several times asking if it was acceptable to pre-print an attestation statement on our forms but have not recieved any feedback. Can anyone else billing for teaching facilities tell me wheather or not they are doing this and if so can you send me a link or something to show proof. I have tried researching on the internet, asked several people when i attended seminar's and webinar's and no one seem's to have a simple yes/no answer. They all say they will research and get back with me and no one does. We are looking into revising all our forms by April 1 and would like to know before then so we can add this. Any help is appreciated. Thank you in advanced.

  10. #10
    Default Resident's again
    Is anyone else billing for resident's and if so can they please tell me if they have a pre printed attestation on their forms ?? I have been researching and can't find anything. Thanks

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