Wiki Question about PA office notes

[Coastal Coder]

Hello,
I am in a private urology practice in NC and one of my Dr's heard from someone at the hospital that the PA's their can sign their own notes without being signed by a Dr.
He ask me to find out if we (in an office setting) still need to have a Dr from the office sign our PA's notes or can he sign by himself.

Any help with this would be greatly appreciated.

THanks

Michelle L English CPC
Billing Supervisor
Urology Associates of SENC, PA

 

[btadlock1]

Hello,
I am in a private urology practice in NC and one of my Dr's heard from someone at the hospital that the PA's their can sign their own notes without being signed by a Dr.
He ask me to find out if we (in an office setting) still need to have a Dr from the office sign our PA's notes or can he sign by himself.

Any help with this would be greatly appreciated.

THanks

Michelle L English CPC
Billing Supervisor
Urology Associates of SENC, PA

It depends on how you plan to bill it - if you're billing under the PA, then yes, they can sign their own notes. If you're planning on billing 'incident-to' (for Medicare only, of course), then remember that the physician has to have performed the initial evaluation of the problem, and set the treatment course (so: no new problems, or new patients). That initial evaluation doesn't necessarily have to be documented in the current visit, as long as it's been documented at some point.
The physician also has to maintain an active role in the management of the patient's problem, for 'incident-to' to apply, so he will need to see the patient (and create his own notes), periodically. It's not generally considered 'acceptable' for a doctor to co-sign a PA's notes, unless the PA is scribing for the doctor - the notes should be the doctor's, if he's going to sign them, as though they're his. Hope that helps!