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MRA Thought of the Day – Attestations: Are Your Services Still Billable?

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Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education

Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education

Situation:

Many facilities have had payments retracted by a payer over a non-attested or unsigned operative report. This is 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.

Here are my thoughts…

As part of billing preparation, 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:

  • All locations; Places of Service
  • Completes the patient note
  • Incident To
  • Attending TIME only

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.”
  • “…Dr. Surgeon (or I) was present and scrubbed for the key portions of the procedure and was immediately available during the entire procedure”
  • Electronic Signature to finalize the operative report

Scenario 2 Clinic:

  • The resident performs the elements required for an E/M service with or in the presence of 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.)

Scenario 3 Clinic:

  • The resident/fellow performs some or all of the required elements of the service in the absence of the attending/teaching physician and documents his/her service. The attending/teaching physician independently performs the critical or key portion(s) of the service with or without the resident/fellow present and, as appropriate, discusses the case with the resident/fellow. In this instance, the attending/teaching physician must document that he/she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient.

Examples of minimally acceptable attestations:

  • “I saw and evaluated the patient. I reviewed the resident/fellow’s note and agree, except that picture is more consistent with…Will begin patient on …”
  • “I saw and evaluated the patient. Discussed with resident/fellow and agree with resident/fellow’s findings and plan as documented in the resident/fellow’s note.”
  • “See resident/fellow’s note for details. I saw and evaluated the patient and agree with the resident/fellow’s finding and plans as written.”

UNACCEPTABLE ATTESTATIONS

  • “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.

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.

What are your thoughts?

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