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MD taking over an NP's note

Janet Posted Fri 06th of April, 2018 08:45:25 AM
Do you know if there are any rules or regulations established regarding an MD taking over ownership of an NP's progress note. Example: the NP goes in to see the patient (in the hospital) he does the history and exam and then the MD comes in later and does a complete history, exam (all the requirements to meet 9921_). Can the MD edit the NP's progress note to add his part of the history, exam and decision making and signs the record as his own. We are unable to find anything that states if this is acceptable or not? Thanks
SuperCoder Answered Mon 09th of April, 2018 05:01:07 AM

Hi,

Yes, it is acceptable. It is called Split or shared visits.

Please check the below links:

https://medicare.fcso.com/faqs/answers/157200.asp

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf

 

Thanks

Janet Posted Mon 09th of April, 2018 08:52:11 AM
We do the split / shared visits now .. but this is a provider that does not want to do the split / shared visits. He wants the NP to just go in ahead of him and start the history and exam and then he will take the NP 's note and edit it with his information and part of the exam and then bill for the visit. To take over ownership of the NP's note. Does this make sense? Thanks
SuperCoder Answered Tue 10th of April, 2018 07:08:59 AM

Yes, MD can take over ownership of an NP's progress note provided both agree to each other’s findings and sign at the bottom of the medical documentation. MD can later bill for this service in HCFA 1500 under his NPI (National Provider Identification) number.

 

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