tci Part B Insider - 2013 Issue 19

Reader Question: Residents' Notes Require Linking Statement

Question: If no linking statement by the attending is present, which part of the resident’s note may be used in leveling an E/M Service for a Medicare patient?   Answer: There has to be a linking statement along the lines of those pasted below from Transmittal 2303. Additionally, though the ROS and Past/Family/Social History may be gathered by anyone they must be reviewed and confirmed by the physician. Following are examples of minimally acceptable documentation from CMS: ·         “I performed a history and physical examination of the patient and...

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