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NP or PA Dictates Surgical Procedure

  1. #1
    Default NP or PA Dictates Surgical Procedure
    Medical Coding Books
    If an NP/PA is an assistant at surgery, is it acceptable for the NP/PA to dictate the procedure note and the surgeon to sign off on it?? I have not found a source stating either way on the CMS website. Your help is much appreciated.

  2. Default
    The performing surgeon should dictate his own OR report. The PA is supposed to be assisting so I really dont see how they could accurately dictate the main components of the surgeon's procedure. Also, from a liability standpoint I wouldnt think that the sureon would want the PA to document something he is legally responsible for. It is not a good idea for the PA to dictate the OR.

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Yes, it can be done
    Quote Originally Posted by penguins11 View Post
    The performing surgeon should dictate his own OR report. The PA is supposed to be assisting so I really dont see how they could accurately dictate the main components of the surgeon's procedure. Also, from a liability standpoint I wouldnt think that the sureon would want the PA to document something he is legally responsible for. It is not a good idea for the PA to dictate the OR.
    Penquins11 ... by your reasoning, then, residents (who are usually listed as assistant surgeons but cannot be billed at all) would never dictate op notes. But, in fact, they frequently do dictate.

    It is acceptable for the assistant surgeon (even if a PA or NP) to dictate the note, but the dictation should clearly state the dictator's role in the procedure, and the full participation of the primary surgeon. In our teaching hospital, PAs or NPs will occasionally dictate notes when they assisted the surgeon, but BOTH the surgeon and PA/NP must sign off. The surgeon must also clearly attest to his/her participation and presence for that procedure.

    NOTE ... the requirements of documentation / credentialling frequently require that the supervising physician/surgeon sign each note. Our system will list the PA/NP as the "assistant surgeon" and the supriving MD as the "primary surgeon" even in those cases where the PA/NP was performing the procedure on his/her own. We require very specific verbiage in these cases to clearly outline WHO performed the procedure. For example: "PA X performed this procedure on behalf of Dr Supervisor." This lets our billing staff know that the procedure will be billed under the PA/NP's name, with the MD listed as supervising. Both the PA/NP and the supervising surgeon will sign the note.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. Default
    In my state and in the type of procedures my doctor performs, the PA is not qualified to solely perform the procedure on their own, they would only be assisting. I still feel that the surgeon should dictate his own note because our PA's are not qualified or can legally solely perform complicated spinal or brain surgeries. The surgeon must do the surgery and the PA assists with suction irrigation, instrumentation etc.

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