Wiki Attending Attestation

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dballard2004

dballard2004

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I have a question on the attending attestation for a dermatology provider, please....

This is an attending supervising a resident for a dermatology surgery. Here is an example of his attestation:

"I saw and examined the patient. I reviewed the history, physical exam findings, and assessment and plan as documented above and agree. All questions answered. Patient verbally expressed understanding and agreed to plan. I was present for the entire procedure."

Is this sufficient as written? I think he must either document that he performed the entire service himself or was present during the critical and key portions of the service in the case of resident supervision. I am basing this on the CMS teaching guidelines: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R811CP.pdf

Any guidance appreciated. Thanks.
 
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My opinion and it depends on the type of surgery. I would also want to see the full documentation.

It could be better and not just the same old macro they use for everything else. It would meet the absolute, bare minimum though I think. That macro sounds more like the E/M type you would see. If it is for a surgery they could have a better one. It states he was present for the entire procedure though. Especially if it was a minor procedure. According to the link: "3. Minor Procedures For procedures that take only a few minutes (five minutes or less) to complete, e.g., simple suture, and involve relatively little decision making once the need for the operation is determined, the teaching surgeon must be present for the entire procedure in order to bill for the procedure."

See also: 100.1.2 - Surgical Procedures (Rev. 2303, Issued: 09-14-11, Effective: 06-01-11, Implementation: 07-26-11) In order to bill for surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.

So, it might be improved if it said, "during all critical and key portions" and/or immediately available. But it does say he was present for the entire thing.
 
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Since he said that he was present during the entire procedure, then it would be reasonable to infer that he attended during the key and critical portions. From Transmittal 811, CR 3928: Single Surgery: When the teaching surgeon is present for the entire surgery, his or her presence may be demonstrated by notes in the medical records made by the physician, resident, or operating room nurse. For purposes of this teaching physician policy, there is no required information that the teaching surgeon must enter into the medical records. The guidance becomes stricter if the teaching physician is moving between OR suites and supervising more than one surgical session.
 
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