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provider documentation

  1. #1
    Default provider documentation
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    I have a orthropedic surgeon that has 2 pa's working under him, he travels to 5 hospitals a week, so the pa's are responsible for making hospital rounds, the pa that makes rounds at my hospital was on vacation so pa-2 made rounds on the patient. When he came to work the next week and saw that the discharge summary was not done, dictated the summary without ever seeing the patient. Is this ok, does anyone know of documentation requirments for providers that i can show pa-1. I do not feel that i can code from this discharge summary because he never saw the patient. What do you think?

  2. #2
    Milwaukee WI
    Default Surgical patient?
    If the patient had surgery then you cannot code the discharge in any case - it is bundled in the surgical procedure as part of post-operative care.

    If the patient was non-operative (hard to imagine for orthopaedics) ... then you are right, you cannot code if the patient was not actually seen. (The hospital probably still requires a discharge summary, though.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Your Hospital should also have specific Guidlines set up for instances like this.

    Example: all charts must be signed with in 24 or 48 hrs.

    Check with your Compliance Mananger or Office Manager to see.

    And i agree, it cant be coded with out a Signature

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