NEED DOCUMENTATION FOR WHY THE OPERATING PHYSICIAN MUST DOCUMENT THE PROCEDURE

We have doctors that feel that the PA assisting at surgery or another doctor is assisting at surgery and that PA or doctor can document the procedure, not the physician that actually was the operating surgeon. They response to me is that well we did it when I was a student.

Can anyone tell me where to look to find the guidelines. You know they need to see it in writing before they will believe you.

Comments

  • Duh doctor.. wow they are getting a bit lazy..

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • edited May 2017
    “A frequent question Medicare receives is whether or not an assistant surgeon must sign the operative report. The answer is no. The primary surgeon must document, with specificity, the activities the assistant surgeon performed and that the additional “skilled” operative assistance was needed to perform a medically necessary and otherwise covered Medicare service. The primary surgeon must authenticate his/her entry in the medical record, but the assistant surgeon need not sign the operative report. Providers need to be cognizant that a non-restrictive assistant surgery payment indicator on the Medicare Physician Fee Schedule Database does not alone determine that Medicare will approve payment for an assistant at surgery service.”
    http://www.wpsmedicare.com/j8macpartb/departments/cert/documentation-assistant-surgery-services.shtml


  • Right but she is stating that the doctor states that the assistant can document the procedure report, i.e. that he doesn’t need to is the way that I interpret this.

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382


  • I might be misinterpreting the question but residents dictate operative reports for the attending all the time. Of course they must be authenticated by the attending physician and the dictating resident must state he is dictating for.the
    attending.

    Sharon Cohen



  • True…but I think it this case they think that the assistant should document it, I mean can they- probably yes as long as they sign off on it but is it the best practice? I guess maybe they feel like they don’t have the time ??

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • edited May 2017
    Usually the hospital/facility will have policies that indicate who must document operative notes. Check with your facilities.



    From: Karyn Foray [mailto:Karyn.Cardenas-Foray@sharp.com]
    Sent: Wednesday, November 2, 2016 12:19 PM
    To: Multiple recipients of list PARTB-L
    Subject: RE: [partb-l] NEED DOCUMENTATION FOR WHY THE OPERATING PHYSICIAN MUST DOCUMENT THE PROCEDURE



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