tci ED Coding & Reimbursement Alert - 2003 Issue 2

Documentation Faux Pas for New TP Guidelines

For the new teaching physician guidelines, some documentation decisions do not pass muster. Make sure you don't submit insufficient physician documentation, and apply documentation rules to the wrong codes.Unacceptable Documentation According to the guidelines, the following examples of teaching physician documentation are unacceptable and won't get your physicians paid:"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 A legible countersignature...

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