Internal Medicine Coding Alert

Question: Our physician works with residents each year. It's very time consuming, but he does review their documentation and indicates whether he agrees with their findings. He doesn't use a rubber stamp -- he actually writes, "Seen and agreed" on the chart before he signs it. A consultant told us during an audit that documenting this way is unacceptable. Can you explain the problem?

California Subscriber

Answer: The consultant is correct. Although you're correct in knowing that a "seen and agreed" rubber stamp is unacceptable, CMS says a handwritten note of the same phrase is also a no-go.

Explanation: "Seen and agree," followed by a legible countersignature or identity is an example of unacceptable documentation, according to CMS' Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 100.1.1, which you may find online at http://www.cms.gov/manuals/downloads/clm104c12.pdf. Other examples of similar documentation CMS also considers unacceptable include, "Rounded, reviewed, agree" and "Discussed with resident. Agree."

Better way: The manual offers examples of acceptable documentation. For example, your physician's documentation might begin, "I saw and evaluated the patient. I reviewed the resident's note and ..." Then the doctor can elaborate on whether he agrees with the resident and why or why not.