Wiki Dictation Question

[keallen]

We had an assistant surgeon dictate an operative report for the primary surgeon and we are having an issue getting the claim paid since the signing physician's name does not match the primary surgeons name. Both providers for this date of service are MDs and belong to the same practice. Does it matter who dictated the operative report?

Thank you!!

 

[Donna T]

Yes, it does matter. The primary surgeon (surgeon of record) dictates the operative note. He or she should dictate the role, medical necessity, and work performed by an assistant (if one is involved in the surgery). If an assistant surgeon (MD or DO) or an assistant at surgery (PA, NP, or CNS) is used, the primary surgeon is responsible for justifying the presence of the assistant, the medical necessity requiring the assistant’s presence, and the work performed. Hope this is helpful in getting your claim paid!

 

[keallen]

Thank you! Do you have any supportive documentation for this information that I can present to our doctors? I know they're going to ask when I tell them the report needs to be corrected. I looked before I posted the question but could not find a definite answer as to who can dictate.

 

[Donna T]

I've actually had this on file from when I worked ortho - I got it from the AAOS website but the article itself was written by Mary LeGrand who is a consultant for Karen Zupko. Here is the link to the article.

http://www.aaos.org/news/aaosnow/apr10/managing1.asp

 

[keallen]

Thank you very much. This is very helpful. I appreciate it!!