# Physician's and residents



## cpccoder2008 (Jan 26, 2010)

When a patient is seen by a resident along with a physician the staff is supose to write documention showing his involvment. That part we understand. Our doctor's usually exam the patient after the resident and write something like " Patient seen and examined along with resident, agree with all residents findings" Or "Patient seen and examined along with resident, agree with resident's findings except for ____ " My question is, can we apply this statement to our actual medical record and have the doctor check it off wheather he was present or not and sign or does he have to physically write this statement each time. Also they want to know if they can make a stamp with this actual statement that way they just have to sign and make any changes to the findings. I know that CMS clearly states no stamp signatures but this wouldn't be a signature, it woud be an automatic statement that is on every progress note. Thank you in advanced.


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## LTibbetts (Jan 26, 2010)

Now, I'm not positive but I would venture a guess of no way. I'm not even sure that the documentation that your teaching physician is doing is appropriate. I am taking some E&M courses right now and they state that the teaching physician has to provide the exam and make his own determinations. I think that he can state that he agrees with the student but he must still perform his own evaluations independant of the student. It doesn't mention a stamp for that use anywhere and I seriously doubt that they would allow it, but I could definitely be wrong.

As I said, I am not completely sure about all of this but below I put the web address of a copy of the MLN matters for teachings physicians and documentation guidelines. Read it and maybe it covers these questions. Just my opinion, and I hope it helps

http://www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf


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## FTessaBartels (Jan 26, 2010)

*Check with your carrier*

Some of these rules are carrier specific, so be sure to check with your carrier.

There is a difference between residents and students. Residents have their MD and are licensed physicians, but are in a post-graduate training program. (Every year there are MDs who go into practice without completing a residency program.)  Students have not yet completed their medical school training and do not have an MD. The only part of a student's documentation that can be used is the ROS and PFSH (which can be taken by anyone, even someone off the street). 

We are in a large teaching hospital. Many of our forms (e.g.H&P, Consults) have a pre-printed attestation statement that the teaching physician can check and then sign/date. This is considered acceptable documentation of physician presence and involvement when the originator of the document is a resident. 

This is really not much different than having templated information in an EMR that only requires a "click" to add an entire phrase. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## cpccoder2008 (Jan 26, 2010)

Yes for student's the staff must personally perform the exam and ros but for resident's the staff can refer to the note. I have several article's refering to teaching facilities and the one we refer to the most states _" Following are minimally acceptable documentation for each of these senarios- I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the residen'ts note. I saw the patient with the resident and agree with the resident's findings and plan"_ The teaching physician's must document he personally saw the patient, personally performed key portions or critical portions of the service and participated in the management of the patient. They just want to make this note a part of the medical record and be able to check off and make any notation's along with their signature. Thanks again


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## cpccoder2008 (Jan 26, 2010)

FTessaBartels said:


> Some of these rules are carrier specific, so be sure to check with your carrier.
> 
> There is a difference between residents and students. Residents have their MD and are licensed physicians, but are in a post-graduate training program. (Every year there are MDs who go into practice without completing a residency program.)  Students have not yet completed their medical school training and do not have an MD. The only part of a student's documentation that can be used is the ROS and PFSH (which can be taken by anyone, even someone off the street).
> 
> ...



Yes that's exactly what they want, a pre-printed attestation statement that the teaching physician can check and then sign/date or a stamp. We have kinda gotten the run around from our local carrier's. When we say stamp they think signature, when we try to explain they get confused, for the most part we are hearing yes as long as they sign and date with a notation. Would you mind sending me a blank copy of your H&P form so i can show them ? Or could you tell me what your statement says. I would really appreciate it. Thanks


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## cpccoder2008 (Jan 26, 2010)

cpccoder2008 said:


> Yes for student's the staff must personally perform the exam and ros but for resident's the staff can refer to the note. I have several article's refering to teaching facilities and the one we refer to the most states _" Following are minimally acceptable documentation for each of these senarios- I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the residen'ts note. I saw the patient with the resident and agree with the resident's findings and plan"_ The teaching physician's must document he personally saw the patient, personally performed key portions or critical portions of the service and participated in the management of the patient. They just want to make this note a part of the medical record and be able to check off and make any notation's along with their signature. Thanks again



Sorry, the students can perform the ROS and PFSH, the exam has to be performed by the staff, we don't have student's in the area i code only resident's, so i wasn't sure.


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## FTessaBartels (Jan 26, 2010)

*Attestation statements*

There are a couple of different forms; here are two attestation statements that are pre-printed on forms used at our hospital:

I have seen and examined this patient on rounds with the surgical residents and/or PAs, reviewed the pertinent diagnostic data and agree with what is written above. My assessment and plan of management has been discussed with the surgical residents and PAs, and is reflected in this history and physicial examination/consultation.  (followed by area for Attending Physician Signature   and Date/time)


History reviewed, patient examined, discussed with Intern/Resident. Agree with assessment and plan as written. See additional note in progress section. (Followed by area for Attending Physician signature and Date/Time)  

NOTE - Our attendings typically dictate an H&P or Consultation note in addition to what is written on the form by the resident.  That dictation usually refers back to the resident's documentation for ROS and PFSH. 

RE STAMPS - I would stay away from stamps. As you have discovered the carriers really don't like them. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## cpccoder2008 (Jan 26, 2010)

Thank you, i will check with our carrier to see if these are acceptable in our area, thank you again


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## cpccoder2008 (Feb 25, 2010)

*No reply*

I have contacted our local carrier several times asking if it was acceptable to pre-print an attestation statement on our forms but have not recieved any feedback. Can anyone else billing for teaching facilities tell me wheather or not they are doing this and if so can you send me a link or something to show proof. I have tried researching on the internet, asked several people when i attended seminar's and webinar's and no one seem's to have a simple yes/no answer. They all say they will research and get back with me and no one does. We are looking into revising all our forms by April 1 and would like to know before then so we can add this. Any help is appreciated. Thank you in advanced.


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## cpccoder2008 (Mar 3, 2010)

*Resident's again*

Is anyone else billing for resident's and if so can they please tell me if they have a pre printed attestation on their forms ?? I have been researching and can't find anything. Thanks


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## deyoung (Mar 3, 2010)

We bill for our supervising physicians who see patients with residents and have pre-loaded attestations in our EMR. Here's an example of what may go on the bottom of the resident's note:

I saw the patient on 2/15/10, performed psychiatric evaluation with psychiatry resident, Dr. X, and discussed case with her.  I reviewed her note and agree with the documented findings and plan of care. For details of evaluation and plan of care see her note.

Prior to EMR, we did have a pre-printed statement on our paper notes. 

Hope that's helpful.


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## cpccoder2008 (Mar 3, 2010)

According to the medicare guidelines it was ok to have it within the EMR but i wasn't sure about pre printed. I have spoken to a few people who say they have a pre printed form also and they check with their local carriers first but unfortunetly i haven't recieved feed back from ours. Would you mind telling me what state your in ?? We are in Louisiana. Thank you soo much for replying, we are trying to get as much feedback as possible. We would also like to contact other carrier's to see if they can provide us with documentation stating they except this so that we have something to show our medicare rep's.


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## cpccoder2008 (Mar 3, 2010)

FTessaBartels said:


> There are a couple of different forms; here are two attestation statements that are pre-printed on forms used at our hospital:
> 
> I have seen and examined this patient on rounds with the surgical residents and/or PAs, reviewed the pertinent diagnostic data and agree with what is written above. My assessment and plan of management has been discussed with the surgical residents and PAs, and is reflected in this history and physicial examination/consultation.  (followed by area for Attending Physician Signature   and Date/time)
> 
> ...



Would you mind telling me your local carrier also ?? Like i metioned before we are trying to contact as many carrier's as possible to see if they have documentation on weather or not they accept this and if so then at least we have something to show our med rep. Thank you


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## deyoung (Mar 3, 2010)

I am in Hawaii. Our carrier used to be Noridian and now it is Palmetto. I don't know if our local carriers were ever asked about the pre-printed paper note (these were used prior to me working here) but we work within a hospital so I would think if it had been a problem the hospital wouldn't have allowed us to use them. Good luck, I know it's terribly frustrating trying to get answers from the carriers.


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## cpccoder2008 (Mar 3, 2010)

Yes and this is something our docs would like pre printed on our forms and it has to be approved so before we can say "hey add this" we have to show proof or something as to why we want this and make sure it is ok before we do it. I think our local carrier is pinnacle but they were having a fued over wheather it would be trailblazer or pinnacle.


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