Last Modified: 5/7/2020
Location: FL, PR, USVI
Business: Part A, Part B
Q. If a physician's assistant (PA) gathers initial information and the physician performs the examination and medical decision making, but the PA dictates the office note, do both the physician and PA need to sign the record for proper documentation?
A. This depends on whether the service is a split/shared visit or if the visit is considered "incident to."
When an evaluation and management (E/M) service is a split/shared encounter between a physician and a non-physician practitioner (NPP), the service is considered to have been performed incident to the physician if the requirements for "incident to" are met and the patient is an established patient. If "incident to" requirements are not met for the split/shared E/M service, the service must be billed under the NPP's national provider identifier (NPI).
A split/shared E/M visit is defined by Medicare as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, examination or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.
If the physician's signature is the only signature on the visit, Medicare assumes that he/she is indicating they personally performed the visit. Notes recorded in the patient's medical records by another provider are considered relevant documentation of the encounter. Documentation may be dictated and typed or hand-written, or computer-generated and typed or handwritten. Documentation must be dated and include a legible signature or identity.
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