Resident admitting patient late at night

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Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Mon Mar 19, 2018 3:39 pm

If a resident admits a patient late at night and does a complete history, exam and A & P. This day is not billed. The attending sees the patient the next day and personally performs an exam and Assessment & Plan while and directly refers to the patients History components, can those be counted for the attending to get a complete H & P on the day he sees the patient.
Note states: "Please see resident H & P for additional and complete history documentation. Patient is 57 year old with history of ankle dislocation and fracture that is post-surgical care. She is doing well, pain is controlled. No additional complaints. Denies fever/chills/SOB. On exam she is not in distress, alert and oriented, PERLA, Cards-rrr, no mumurs, lungs-CTA bilaterally, abd-NT, ND, Good bowel sounds, Skin- surgical dressing intact with no drainage, left leg with no edema. She has been cleared by ortho for discharge. Waiting for PT assess to ensure patient is capable of moving with walker. Medical issues are stable and has had not post-op or surgical complications She will need pain control for a few days and to be non-weight bearing until released by ortho. She will need work excuse and restrictions until cleared by ortho in 2 weeks. Anticpate discharge today after PT assessment. Patient seen and dw resident team - Dr. A, Dr. B and Dr. C.
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Tue Mar 27, 2018 10:08 am

The statement from the attending has to clearly state they (personally) saw and evaluated the patient, reference the date of servie and document, and attest to the documentation for it to be counted. It is then billed for the day the attending saw the patient.

Good example: I personally saw and evaluated Mr Smith, today 3/26/18. I agree with the documentation done by Dr Resident on 3/25/17, in addition........

Insufficient: Patient was seen and evaluated, I agree with the documentation done by Dr. Resident on .....

Your question has been answered by Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC
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Joined: Wed Mar 28, 2018 6:54 am

Wed Mar 28, 2018 6:58 am

What happens if there is no date noted by the admitting on when exactly he or she saw the patient? The attestation would say that he examined the patient and agree with the resident and his/her additional comments, etc. Which DOS should be reported? This is an issue I see a lot.
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Joined: Mon Feb 27, 2017 12:27 pm

Mon Jul 09, 2018 9:26 am

As per CMS transmittal 2303:
The teaching physician’s bill must reflect the date of service he/she saw the
patient and his/her personal work of obtaining a history, performing a physical,
and participating in medical decision-making regardless of whether the
combination of the teaching physician’s and resident’s documentation satisfies
criteria for a higher level of service. For payment, the composite of the teaching
physician’s entry and the resident’s entry together must support the medical
necessity of the billed service and the level of the service billed by the teaching
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