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question on DC

  1. #1
    Question question on DC
    Medical Coding Books
    Hi everyone,

    I work for a teaching facility, and am looking for guidelines regarding DC patients. I was told that the attending has to dictate/document the DC themself, not just sign off on what the resident has documented. I need verification to support or dispute this please.
    Malama pono,

    Sundae Yomes

  2. #2
    Milwaukee WI
    Default Teaching Physician PRESENCE
    For government payers -- In a teaching facility, the teaching physician must attest that s/he was actually present and participated in the exam, assessment and medical decision making. Just counter-signing a resident's note is NOT sufficient documentation.

    For commercial payers -- MOST commercial payers define "supervision" as by any means of communication. If the resident says s/he discussed the case with Dr Teaching Physician that is usually considered sufficient. A counter-signature is also frequently accepted. This will depend on how your payer defines supervision, and may vary greatly from payer to payer.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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