# physicians dictating for other physicians



## nelsonml (Jul 23, 2012)

I have never heard of this, but a practice is allowing one physician to dictate the operative report for another physician. They were both in the room and participated in the surgery. I am getting the rationale that it is no different than a resident dictating the report. The dictating physician is the assistant and they are dictating for the primary surgeon. Both are from the same practice. I always thought that the primary surgeon needs to dictate. 
Can someone please let me know if this is allowed??/????
Thanks!
Michelle


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## Donna T (Jul 23, 2012)

You are absolutely correct.  The primary surgeon (surgeon of record) dictates the operative note. He or she should dictate the role, medical necessity, and work performed by an assistant (if one is involved in the surgery). If an assistant surgeon (MD or DO) or an assistant at surgery (PA, NP, or CNS) is used, the primary surgeon is responsible for justifying the presence of the assistant, the medical necessity requiring the assistant’s presence, and the work performed.

An assistant, who is billing for his or her services, does not dictate an operative note. If the primary surgeon does not include the information in the operative note, there is no basis to report the assistant’s service. If the bill is denied, the assistant has no documentation to support an appeal.

Donna


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## nelsonml (Jul 24, 2012)

Thanks Donna-
Do you know where I can find the guidelines for this?
I need it to go back to the docs with-

Michelle


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## Donna T (Jul 27, 2012)

I got this information on the american academy of orthopedic surgeon's website.  The article was written by Mary LeGrand who is a consultant with Karen Zupko and Assoc.  Here is where I got the article...information is great regardless of the specialty.

http://www.aaos.org/news/aaosnow/apr10/managing1.asp


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