Oncology & Hematology 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. Instead, 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 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's Medicare Claims Processing Manual, chapter 12, section 100.1.1 (www.cms.gov/manuals/downloads/clm104c12.pdf). Other examples of what CMS considers unacceptable teaching physician documentation include, "Rounded, reviewed, agree" and "Discussed with resident. Agree."

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