ortho1991
Guru
Documentation of incident to billing.
May 26 2014
FU L ankle
Diagnosis: Status post left ankle ORIF, February 20, 2014.
Disposition: Followup as needed.
Interval History: PT returns today for followup of his left ankle. He has finished physical therapy. He returned to work full duty, May 21, 2014. Overall, he is doing very well. He is still complaining of some numbness and tingling over his great toe, but does feel that he has been improving.
PE: On physical exam today, his incision is well healed. There is no tenderness to palpation over his medial and lateral malleolus. No pain with range of motion of his ankle. He does continue to note some decreased sensation over his great toe. Otherwise, his sensation is intact to light touch. His distal strength is 5/5
Imaging: X-rays taken in the office today; AP, lateral, and mortise views of his left ankle show his hardware to be in excellent position with his fracture to be well healed.
Plan: PT will continue with activities as tolerated and followup as needed.
Dr was in to reevaluate and reexamine the patient and agrees with the assessment and plan.
MD
Dictated By: PA-C
Is this proper dictation for incident to billing?
The PA see the pt does evaluation of pt Dr. comes in speak to pt and PA agrees with assessment as stated above, who should be signing off on this note the Dr. or the PA? This is a Medicare pt.
And if not a Medicare pt who needs sign note?
Any thoughts or suggestions on this are appreciated
Thank you
May 26 2014
FU L ankle
Diagnosis: Status post left ankle ORIF, February 20, 2014.
Disposition: Followup as needed.
Interval History: PT returns today for followup of his left ankle. He has finished physical therapy. He returned to work full duty, May 21, 2014. Overall, he is doing very well. He is still complaining of some numbness and tingling over his great toe, but does feel that he has been improving.
PE: On physical exam today, his incision is well healed. There is no tenderness to palpation over his medial and lateral malleolus. No pain with range of motion of his ankle. He does continue to note some decreased sensation over his great toe. Otherwise, his sensation is intact to light touch. His distal strength is 5/5
Imaging: X-rays taken in the office today; AP, lateral, and mortise views of his left ankle show his hardware to be in excellent position with his fracture to be well healed.
Plan: PT will continue with activities as tolerated and followup as needed.
Dr was in to reevaluate and reexamine the patient and agrees with the assessment and plan.
MD
Dictated By: PA-C
Is this proper dictation for incident to billing?
The PA see the pt does evaluation of pt Dr. comes in speak to pt and PA agrees with assessment as stated above, who should be signing off on this note the Dr. or the PA? This is a Medicare pt.
And if not a Medicare pt who needs sign note?
Any thoughts or suggestions on this are appreciated
Thank you
