Hello All,
I am in need of feedback on the following situation...

Pain doc seeing patients in his office, but is considered an Out Patient (POS 22) site of service. He has a PA working with him as well. Since they fall under “split/shared visits” and not “incident-to” due to the POS, the issue of documentation requirements have been asked to be specifically drawn out. I have done this, explaining that each the MD and PA must see the patient and each document their portion of the E/M. Not a problem…until I actually get the documentation to review. Prior to this date in time, the PA was dictating and the MD would come in at the end, do his bit and the documentation stated “pt was seen by dr. x and myself….WE are planning to perform…WE will see pt in….” Since this is the PA’s dictation in his own words and his signature, it was deemed that the MD’s involvement was not properly documented. Then the documentation went to the PA dictating in first person (I instead of ‘we’)…and now they have asked if the following can be added to the PA’s dictation and suffice as the MD’s involvement and thus be compliant with split/shared visit doc requirements:

Usual E/M documentation with PA’s signature…then comes “ADDENDUM: PT SEEN, DX WITH RADICULOPATHY, WILL BE SCHEDULED FOR A TRANSFORAMINAL ESI.” MD’s initials

Any and ALL comments welcome. Thanks in advance for your time!