Wiki TP/Resident Attestation--not sure if this is correct

[coder25]

Hello all,

I am not sure what to do with this hospital consult for a medicare patient and need some help.

The resident wrote on the consult sheet the HPI/Social history/Family history/ROS/Labs, however, the TP wrote the exam/impression/and plan. She also then dictated the complete consultation.

There is no formal attestation written. If the doctor hand wrote the exam/impression/plan and the resident dictated the entire consult, would this still be considered billable???

I am thinking it is but wanted other opinions to be sure.

Thanks.

Peggy

 

[FTessaBartels]

There should be attestation

There should be some reference in the teaching physician's documentation to the resident's note and his/her (the TP's) concurrence with the resident's documentation.

In you suggested scenario - the TP handwrites everything and the resident dictates ... you would code based on what the TP wrote.

Hope that was helpful.

F Tessa Bartels, CPC, CEMC