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Documentation Guidelines for Co-Providers

  1. Default Documentation Guidelines for Co-Providers
    Clearnace Sale
    Please read the following scenario and offer your opinions on whether or not the billing is appropriate.

    An MD and a nurse practitioner from the same practice see a patient in the hospital on consult (old 99254, now 99222). They split duties in that the nurse practitioner takes the history and the MD performs the exam and all the decision making. The nurse practitioner completes the dictation for the visit stating clearly that the patient was examined and treated by the MD. Is it appropriate to bill under the MD's ID if the nurse practitioner has dictated the note?

    Thanks so much for your advice!

  2. Default
    We have this incident happen often, and as auditors it is often unclear from documentation who saw the patient. In this case, the NP indicates the physician saw the patient and performed physical and mdm. So, the NP should follow scribe guidelines and indicate he/she acted as scribe. The physician should indicate he/she read and agrees with the note dictated by the NP and sign. This should be billed by the MD.

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