Outpatient Facility Coding Alert - 2016 Issue 5
You Be the Coder: Attestation Statements Hold the Key to Accurate Billing
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Article Overview
This article reviews a complex emergency department chart involving a resident, attending physician, and scribe, with emphasis on attestation statements and documentation support for reporting an ED E/M service and associated procedures. It is aimed at coders and billing staff who need to understand how documentation roles, supervision, and timing affect claim support in acute care settings.
Why This Topic Matters
The case highlights how attestation language and documentation ownership can determine whether services are reportable and whether separate procedures are supported on the claim. It is relevant for organizations that bill emergency and critical care encounters and need to align chart review with documentation compliance.
Article Sections
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Question
Introduces the documentation dispute and the concern about whether the chart supports reported services.
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Chief Complaint
Summarizes the presenting problem and immediate clinical context of the encounter.
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History and Background
Provides the patient history, review limitations, past medical history, family history, social history, and home medications.
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Physical Exam
Lists the observed condition and exam findings at presentation.
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Procedures
Documents the procedures performed during the encounter and includes supervising physician attestations.
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Medical Decision Making
Describes the encounter management, treatment course, and overall decision-making context.
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Attestations
Contains the resident, attending, and scribe attestation statements relevant to documentation support.
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Answer
Explains the coding analysis for the encounter and summarizes the reported services and modifier usage.
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On the Claim report
Lists the claim-level code reporting outcome and associated modifiers for the encounter.
What You Will Learn
- How documentation roles can affect billing support in a complex emergency department encounter
- How attestation statements relate to resident, attending, and scribe documentation
- How emergency services and associated procedures may be presented on a claim
- How coders evaluate whether a chart supports separate reportable services
Who Should Read This
- Medical coders
- Billing staff
- Compliance professionals
- Emergency department documentation specialists
- Physician advisors
Codes Discussed
Modifiers Discussed
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