tci ED Coding & Reimbursement Alert - 2001 Issue 3

Reader Question: Missing Chart Information

Question: As I reviewed a group of charts to code, I found that one physician had signed for another either for a physician no longer with the group or someone other than the provider who wrote the final diagnosis. How should I handle coding these charts?Michigan Subscriber Answer: It is common in the emergency department for two physicians to provide service, particularly at shift change. The physician who signs the chart, however, assumes legal responsibility for patient care. Therefore, the last physician to see, diagnose and discharge the patient is generally the physician of record for billing purposes...

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