Wiki Procedure note within the attestation

[amanda19791]

Is there any guidelines regarding procedure note within the attestation? My provider did a g-tube replacement procedure while the patient was seen in the ED but did the note within the attestation. Is this ok to bill or should I ask my provider to do addendum?

Attestation signed by MD​

I performed a history and physical examination of the patient and discussed the patient’s management with the resident and/or physician assistant. 　I reviewed the resident's/physician assistant's note and I agree with the above assessment. 　The plan of care has been formulated together. Relevant labs and imaging have been reviewed. 　I have spoken with the parents at bedside who expressed understanding regarding the plan and all questions answered. Chronic to the child's father, the child's aunt was caring for him and administering tube feeds. 　The and reported difficulty disconnecting the tubing from the button and since then there has been leakage of gastric contents. 　On my exam, the valve inside of the button was broken off and so I would replace this in the emergency department without difficulty and gastric contents were aspirated to confirm placement. Child was discharged home with instructions to restart tube feeds tonight. 　He will follow-up in the pediatric surgery office as needed. ​

​

 

[kjbeams]

Here is an example of an acceptable attestation per CMS Publication 100-08 Chapter 3 Section 3.3.2.4
The attestations I've seen are usually within the body of the author's note...a resident for example...who saw the patient and authored the chart note.
The above looks good...as long as your physician signed and dated it under the paragraph he/she added.