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PA dictating for MD; billing under MD

  1. #1
    Default PA dictating for MD; billing under MD
    Exam Training Packages
    Happy Friday!!!
    Scenario: PA is dictating discharge note for MD; the note is signed by MD only; service is billed under MD who is documenting the following statement "i saw patient and agree with above plan".

    im not comfortable with several areas in the above scenario but primarily i feel the note should be documented by the provider of service but i cant find anything in black and white in the CMS manuals. Does anyone have references/guidelines regarding this?

    Thanks in advance!!
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer
    Previous AAPC Local Chapter President & VP

  2. #2
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    This sounds like a split/shared visit since it is provided in the inpatient setting by a PA and a physician. If they are employed by the same group, the visit may be shared if the PA and the physician both provide a face to face visit. See CMS's guidelines from the IOM here,beginning at the bottom of page 37 of the PDF: http://www.cms.gov/manuals/downloads/clm104c12.pdf
    Jenny Berkshire, CPC, CEMC, CGIC

  3. #3
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    thanks for your response. im pretty familiar with shared visit critier but this is a little different, i think. there is no documentation from the PA that he signs. he is dictating the discharge note but the MD is signing it. this would be okay if the PA was a scribe but hes not attending the visits with the MD so hes not a scribe. .....
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer
    Previous AAPC Local Chapter President & VP

  4. #4
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    Greeley, Colorado
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    I agree with you Dawnelle. The PA should have signed the discharge and billed under his/her own number. The physician should not have signed the PA's note.
    Lisa Bledsoe, CPC, CPMA

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