tci ED Coding & Reimbursement Alert - 2015 Issue 4

Reader Question: Make Sure The Link Is Strong Before Counting Resident Documentation

Question: If no linking statement by the attending is present, which part of the resident’s note may be used in levelling an E/M service for a Medicare patient? Virginia Subscriber Answer:  There has to be a linking statement along the lines of those pasted below from Transmittal 2303. Additionally, though the ROS and Past/Family/Social History may be gathered by anyone they must be reviewed and confirmed by the physician. Following are examples of minimally acceptable documentation from CMS:  “I performed a history and physical examination of the patient and discussed his management with the resident. I...

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