Wiki Audit Question regarding Plann and Assessment

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lauriepaul1115

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I am auditing some family practice claims and have run across a few where the MA has documented the Assessment and Plan. The physician has signed off on the chart but made no reference as to whether or not the documentation is accurate and correct. My question is can someone other than the physician document the treatment plan? The MA is not a scribe I verified that there were no scribes for the physicians. Thanks :)
 
Good morning. It is not appropriate for the MA to document this unless they are acting as a scribe. But from the sound of your message, that is not the case. I would definitely query the provider on this!
Jolene Carter, CPC, CPMA
 
Thank you I was second guessing myself. Do you know where I can find it in writing? You know how the physicians can be if they don't see it in black and white then it isn't true. :D
 
You could look at your state's government website to see what your state considers the "scope of practice" for an MA. Pretty sure you won't find diagnosing a patient ��
 
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