Can an Attending Physician Attest to an NP Consult?

Comparative Billing Reports

Q:Have you ever seen the Comparative Billing Reports before? We received one and I was wondering if you could break down what they are trying to tell us about having higher than average consecutive services. Our physicians think patients want service on the same day, but it appears Medicare believes same-day service is a problem. Am I not interpreting something correctly?

A: Yes, I see a lot of these - they tend to worry people. This is just CMS computers tracking outliers - and this one just says 'higher,' not significantly higher.

That said - it does give you notice that some procedures may be over-utilized. In this case, I'm sure there is necessity for these services, but you may want to have him look at the documentation requirements they provide.

Review of Systems

Q:My provider documents 'all other systems are reviewed and are negative' for the review of systems. He does this on every patient. Isn't this excessive?

A: In a word, yes. There are several things wrong with this. Among them, was the whole system reviewed? Or a specific element reviewed? Can you withstand an inquiry as to these whole 'systems'?

Recognize what these words mean, especially when you use them with great frequency. By saying that 'all other systems are reviewed,' you are stating that you inventoried not only a total of 14 systems, but that you found them all 'negative' – negative for what? For everything that that system could entail? Unlikely.

Make the words match the work – say negative 'for x'. And above all, keep statements like this in proportion to the visit. These have no place on a 99213 or even a 99214.

Attesting to an NP Consult

Q: Can an attending provider 'attest' to an NP consult? I have reviewed some of our doctors' inpatient consults (billed as admit codes). Included in the sample were a few consults that were essentially done by the nurse practitioner and the MD gave only a 'resident-style' attestation:   'Pt seen, above reviewed.  I concur with the above findings, diagnosis and recommendations'

The entire note is written by the NP, who states 'staffed with Dr. X' at the end of her A/P. Is this legal?

A: Setting aside for the moment that Medicare had stated that consults couldn't be split/shared or collaborative (since these were billed with the admit codes) - these would still not appear to meet the standard for a 'split/shared' visit. Although these vary a bit by state, at least one Medicare administrative contractor requires that:

"A split/shared E/M visit is defined by Medicare Part B payment policy 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, exam or medical decision making key components of an E/M service."

The doctor needs to document his her portion of the work, unlike oversight relationship a physician has with a resident.