ED Coding & Reimbursement Alert - 2011 Issue 22
Reader Question: 'Seen And Agree' Notation Might Get Your Service Denied
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Article Overview
This reader Q&A discusses Medicare/CMS documentation guidance for physician review of resident notes and the types of signature notation practices that can lead to claim or record review problems. It is relevant to physicians, residents, compliance staff, and coding or billing professionals who handle medical record documentation policies. The article focuses on CMS manual guidance, examples of documentation language that is considered unacceptable, and a contrasting example of more complete review documentation.
Why This Topic Matters
Documentation language used by supervising physicians can affect whether a service supports billing and withstands audit or denial review. Understanding the CMS guidance helps practices reduce avoidable documentation deficiencies and align resident-supervision workflows with compliance expectations.
Article Sections
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Question
A reader asks about physician review of resident documentation and whether a particular style of signed agreement notation is acceptable.
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Answer
The response summarizes CMS guidance on documentation practices in resident-supervised care and notes that certain agreement-only notations are not acceptable.
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Better way
This section presents a more complete example of physician review documentation and points readers to CMS source material for additional guidance.
What You Will Learn
- How CMS addresses physician documentation of resident-supervised encounters
- Which broad categories of agreement notations are discussed as problematic
- How documentation language can affect compliance and audit readiness
- Where the article directs readers to find the underlying CMS guidance
Who Should Read This
- Physicians supervising residents
- Residents
- Medical coders
- Billing staff
- Compliance professionals
- Practice managers
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