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TP/Resident Attestation--not sure if this is correct

  1. #1
    Default TP/Resident Attestation--not sure if this is correct
    Clearnace Sale
    Hello all,

    I am not sure what to do with this hospital consult for a medicare patient and need some help.

    The resident wrote on the consult sheet the HPI/Social history/Family history/ROS/Labs, however, the TP wrote the exam/impression/and plan. She also then dictated the complete consultation.

    There is no formal attestation written. If the doctor hand wrote the exam/impression/plan and the resident dictated the entire consult, would this still be considered billable???

    I am thinking it is but wanted other opinions to be sure.



  2. #2
    Milwaukee WI
    Default There should be attestation
    There should be some reference in the teaching physician's documentation to the resident's note and his/her (the TP's) concurrence with the resident's documentation.

    In you suggested scenario - the TP handwrites everything and the resident dictates ... you would code based on what the TP wrote.

    Hope that was helpful.

    F Tessa Bartels, CPC, CEMC

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