Quick EMR Documentation Fix’s May Create Risk
Ever hear about payments being retracted by a payer over a non-attested or unsigned clinic and/or operative reports?
It happens more often than many may realize. Easily overlooked but should be on the priority list, to ensure a service, be it an operative or clinic encounter (E/M), is in fact billable can come down to the attestation/notation within the operative and/or clinic documentation.
As part of preparing your billing, be sure to review all operative reports for completeness, editing for spelling and accuracy, and make sure you are “represented properly” in the documentation.
Attending/Billing Providers who work with a Fellow, NP, PA, Resident/Trainee an appropriate attestation is required
Attestations | Requirements for Medical Billing and Coding
Scenario 1 Operative:
- Attestation for Presence and Involvement of the Faculty Staff
- “Dr. XYZ was present for all critical portions of the operative procedure
- “I was scrubbed and present for the entire procedure.”
- Electronic Signature to finalize the operative report
Scenario 2 Clinic:
- The resident performs the elements required for an E/M service in the presence of, or jointly with, the attending/teaching physician and the resident/fellow documents the service. In this case, the attending/teaching physician must document that he/she was present during the performance of the critical or key portion(s) of the service and that he/she was directly involved in the management of the patient. The attending/teaching physician’s note should reference the resident’s note.
Examples of minimally acceptable attestations:
- “I was present with the resident/fellow during the history and exam. I discussed the case with the resident/fellow and agree with the findings and plan as documented in the resident/fellow’s note.”
- “I saw the patient with the resident/fellow and agree with the resident/fellow’s findings and plan.”
(For payment, the composite of the teaching physician’s entry and the resident/fellow’s entry together must support the medical necessity and the level of the service billed by the attending/teaching physician.)
- “Agree with above.” followed by legible countersignature or identity;
- “Rounded, Reviewed, Agree.” followed by legible countersignature or identity;
- “Discussed with resident. Agree.” followed by legible countersignature or identity;
- “Seen and agree.” followed by legible countersignature or identity;
- “Patient seen and evaluated.” followed by legible countersignature or identity; and
- A legible countersignature or identity alone.
Billing on time attestations – only the attending’s time. If residents are involved, the attending can refer to the fellow/resident’s documentation of E/M components but not the counseling time provided by the fellow/resident.
Such documentation is not acceptable, because the documentation does not make it possible to determine whether the attending/teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.