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Acceptable PA documentation for new complaint - teaching physician environment

  1. #1
    Default Acceptable PA documentation for new complaint - teaching physician environment
    Medical Coding Books
    I work in a specialty department at a teaching physician facility.

    Patient is a f/u of a previous cc but also has a new complaint. What information does the teaching physician need to document. It is my understanding that none of the PA's information in regards to the new complaint is acceptable for billing (not hpi, exam or A & P) and statements by the teaching dr for example: "my exam confirms these findings", "assessment and plan as PA documents" are also not acceptable. Or can the physician refer to the PA's documentation?
    Can anyone confirm this and perhaps lead me to a link or article to show the teaching physician. He is getting annoyed with me sending the charts back to him for complete documentation for the new complaint.
    Thank you!!!

  2. #2
    Milwaukee WI
    Default Bill under PA name/number
    Who is the payer? Let's assume Medicare or Medicaid
    You would bill this under the PA's name/number. The physician cannot take credit for work performed by anyone but him/herself.

    For a commercial payer, however, you'll need to refer to your contracts. Many commercial carriers do not credential PAs or NPs. Some will say you need to bill them under the physician's name/number. Others might say that they follow Medicare's "incident to" rules (which means no NEW problems).

    Be specific when you ask your commercial payer how to handle a claim for service performed by the PA. Get the response in writing.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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