MandyFlagg
Guest
Ihave exhausted my searches and I can't find anything. Wondering if you can help me and lead me in the right direction.
Teaching Physician guidelines:
I have the medicare and I also found a nice article from AHIMA but it does not cover this senario.
The policy I have made for our academic practices is that the attending (preceptor) must document that they personally saw and examined the patient and then give me a piece of history, exam and medical decision making, even for sub hospital days and established patients. We are conservative here. What are your thoughts?
For Family Practice Resident:
Also, for the hospital setting I keep running into this senario. A patient gets admitted, the preceptor (this is a group and is assigned to the night attending) accepts the admission late in the day or overnight. The resident see's the patient when the admission is accepted (late in the day or overnight) the preceptor is not physically in the hospital. The resident then calls and precepts (does the same steps with the physician over the phone that they would do if they were standing next to them) then writes all the orders and dictates. Problem is they use the actual date of admission as their date of service. The preceptor (could be the same as the night preceptor but ususally is whoever is assigned to rounding that week) then rounds on the patient the next day (usually morning) and actually does the face to face portion of that admission (usually the day after the resident has dictated). I know I bill the date that the preceptor does their documentation but is it still OK to combine the residents note with the preceptor? Also, the dictation should list the physician that actually does the H&P with the resident correct?
Ok same senario but with a Family Practice resident rounding as an elective with pediatric hospitalist?
I think this is giving me grey hair!
Teaching Physician guidelines:
I have the medicare and I also found a nice article from AHIMA but it does not cover this senario.
The policy I have made for our academic practices is that the attending (preceptor) must document that they personally saw and examined the patient and then give me a piece of history, exam and medical decision making, even for sub hospital days and established patients. We are conservative here. What are your thoughts?
For Family Practice Resident:
Also, for the hospital setting I keep running into this senario. A patient gets admitted, the preceptor (this is a group and is assigned to the night attending) accepts the admission late in the day or overnight. The resident see's the patient when the admission is accepted (late in the day or overnight) the preceptor is not physically in the hospital. The resident then calls and precepts (does the same steps with the physician over the phone that they would do if they were standing next to them) then writes all the orders and dictates. Problem is they use the actual date of admission as their date of service. The preceptor (could be the same as the night preceptor but ususally is whoever is assigned to rounding that week) then rounds on the patient the next day (usually morning) and actually does the face to face portion of that admission (usually the day after the resident has dictated). I know I bill the date that the preceptor does their documentation but is it still OK to combine the residents note with the preceptor? Also, the dictation should list the physician that actually does the H&P with the resident correct?
Ok same senario but with a Family Practice resident rounding as an elective with pediatric hospitalist?
I think this is giving me grey hair!
