In our outpatient practice, it is accepted that the MA populates a CC line in the EHR template while rooming a Pt. It is also understood that the provider will address the CC in the first area of the Subjective/ROS section of the note. This is found to be acceptable as long as the provider's CC info establishes Medical Necessity, is borne out in the activities *and* is not at odds with the MA's input.
How do any of you experts (I am relatively new at this) feel about a situation wherein the MA's input (not provider work) does well to establish the medical necessity and is borne out in the activities, BUT the provider has essentially broken the documentation by using the 1st area of the Subjective/ROS to state "Pt is here for follow-up"? He is doing this in 7/10 instances
The Medical Director's contention is that the provider signs the note at the end of the visit, having reviewed all of the input, and thereby 'owns' all of it, including the perfectly fine MA input. My contention is that metadata will show that the info input for CC by provider is insufficient and that his theory might work if the provider 'stayed out of the way' of the good input, as well as re-affirming it with a statement attesting that he found same to be true after soliciting the information himself.
My concern is that the MA is providing evidence that s/he is hearing the pt, while the provider is not.
Thanks, this forum is excellent.
How do any of you experts (I am relatively new at this) feel about a situation wherein the MA's input (not provider work) does well to establish the medical necessity and is borne out in the activities, BUT the provider has essentially broken the documentation by using the 1st area of the Subjective/ROS to state "Pt is here for follow-up"? He is doing this in 7/10 instances
The Medical Director's contention is that the provider signs the note at the end of the visit, having reviewed all of the input, and thereby 'owns' all of it, including the perfectly fine MA input. My contention is that metadata will show that the info input for CC by provider is insufficient and that his theory might work if the provider 'stayed out of the way' of the good input, as well as re-affirming it with a statement attesting that he found same to be true after soliciting the information himself.
My concern is that the MA is providing evidence that s/he is hearing the pt, while the provider is not.
Thanks, this forum is excellent.