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!!!
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!!!