Wiki Dictating Physician Different from Performing Physician

[KQuinones0111]

I want to make sure that I am correct in this before billing out the procedure.
Dr. A and Dr. B work in the same group practice and are both present for the patient's cardiac procedure at the hospital.
Dr. B dictates and signs the report but lets me know via personal message that the procedure was done by Dr. A.
Dr. B's dictation states:
Dr. A is the primary operator
Dr. B is the Assistant
Dr. A does not sign the report.

Does Dr. A's signature need to be on the report?

I'm pretty sure it has to be but I'm not sure if by Dr. B mentioning Dr. A on his report is sufficient. I also want to address correct billing guidelines with the physicians so that they are aware.

Thank you!

 

[Orthocoderpgu]

You have multiple problems here. If one was the primary and the other the assistant, the documentation should reflect that. If that is not in the note, send it back. Basically Dr. B is being a scribe for Dr. A. This also needs to be included in the documentation. Dr. A also needs to sign/authenticate the note. If not, it's not billable. Dr. A seems to be coming across as "dictation" or "documentation" is just busy work and is not important. If that doctor is dealing with hearts, they need to understand that this is a legal document to prove what was, and what was not done. I would never want someone else to do the documentation for one of my procedures. This doctor could find themselves in legal trouble and may have to admit that they did not document the encounter in a court. Would not make them look very good at all.

 

[KQuinones0111]

You have multiple problems here. If one was the primary and the other the assistant, the documentation should reflect that. If that is not in the note, send it back. Basically Dr. B is being a scribe for Dr. A. This also needs to be included in the documentation. Dr. A also needs to sign/authenticate the note. If not, it's not billable. Dr. A seems to be coming across as "dictation" or "documentation" is just busy work and is not important. If that doctor is dealing with hearts, they need to understand that this is a legal document to prove what was, and what was not done. I would never want someone else to do the documentation for one of my procedures. This doctor could find themselves in legal trouble and may have to admit that they did not document the encounter in a court. Would not make them look very good at all.

Thank you so much!