Residents and Resident Attending Attestation

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Residents and Resident Attending Attestation

Postby Shoshana » Tue Jan 16, 2018 3:40 pm

I have an Resident attending that may not see the patient for 2 days after admission. Does he get to use the two previous resident notes to get to his chosen acuity on his H & P?

Example: patient admitted by Resident 3 on 1/2/2018 @ 1750. Resident team rounded on 1/3 @ 1530 but no attestation that the Attending saw and examined the patient. On rounding visit on 1/4 @ 0930, attending attestation states he saw and examined the patient and dated and time note appropriately. He also went back and read and signed the two prior notes, but no attestation as a face-to-face. Billing is H & P on 1/4/18 as the first time with the correct attestation. Dates 1/2 and 1/3 are no bill visits.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
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Re: Residents and Resident Attending Attestation

Postby admin » Wed Jan 17, 2018 4:05 pm

Example: patient admitted by Resident 3 on 1/2/2018 @ 1750. Resident team rounded on 1/3 @ 1530 but no attestation that the Attending saw and examined the patient. On rounding visit on 1/4 @ 0930, attending attestation states he saw and examined the patient and dated and time note appropriately. He also went back and read and signed the two prior notes, but no attestation as a face-to-face. Billing is H & P on 1/4/18 as the first time with the correct attestation. Dates 1/2 and 1/3 are no bill visits.

There are two elements in this that need to be answered. You are correct that the DOS the preceptor (attending) sees the patient, is the date of the first visit. Here is where it gets tricky though, the attending is required in all states to see the patient within 24 hours of the admission, so waiting until the third day is really not compliant and has a lot of other considerations. However, as coding specifically, the third day should be billed as a subsequent care encounter, not an initial as it is not really one and only the new and date of service specific documentation is used to support the level of service. Cloned, or copy forwarded notes, are part of the OIG watchlist, and has been since 2012.

The second part, the preceptor should add a statement of clarification to the first two dates of service explaining why the 24 hour rule was not met, or if he/she did see the patient, a supported attestation.

https://www.cms.gov/Outreach-and-Educat ... 006437.pdf

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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Re: Residents and Resident Attending Attestation

Postby Shoshana » Wed Jan 17, 2018 4:35 pm

Thank you for your prompt response. This helps me with educational opportunities.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Shoshana
 
Posts: 67
Joined: Fri Jun 23, 2017 5:41 pm
Location: Multi-specialty Clinic


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