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Exam question

  1. Default Exam question
    Medical Coding Books
    I need some memory help! Can the physician assistant dictate the exam portion of the visit and the physician just make a statement that he concurs with it and point out pertinent findings if any or does the physician have to dictate the whole exam?


  2. #2
    According to the CMS the notation "seen and agree" or simply countersigning is not sufficient. He/she must specifically document what he/she has personally done. The definition of a split/shared visit according to CMS is a medically necessary encounter with a patient, where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face to face with the same patient on the same date of service. This can be found in the Medicare claims processing manual Pub 100-4, chapter 12, section 30.6.1-.13 An article came out on about incident-to and split/shared visits. You should check it out...Lynn

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