BLOG: Construct attestations carefully for teaching physicians, shared visits
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If you perform shared visits with nonphysician practitioners or are a teaching physician, you should learn the lessons taught by a recent settlement involving Baylor University and a few other parties.
One never knows if the allegations in a complaint are true. But, here, one of the claims was that physicians routinely included a tie-in statement indicating they were present for the entire procedure.
Teaching physician rule
The teaching physician rule requires that a physician be present for the key or critical portions of procedure. The rule neither requires nor anticipates the physician will be there open to close, specifically stating that presence during opening and closing is unnecessary. Stating that you were present for the entire procedure is ill-advised if you so much as left for the bathroom during the procedure. If the allegation is true, then the surgeons unnecessarily complicated their lives by claiming they had done more than necessary. If the government can show that the physician was out of the room for just a minute or 2, then they can assert that the documentation was false.
While the physician can argue that the falsity isn’t material, the physician has made his or her life far more difficult than if the physician had simply said he or she was present for the key portions of the procedure. Attestations are often helpful, and in some cases required, but should always be accurate.
Generic vs. tailored attestations
This raises an interesting question: Should a generic attestation be used for every case or should one be created for each patient? Personally, I am a fan of a generic attestation. While it is true that these are boring and formulaic, I worry about the challenge of perfectly wording documentation when the attestation is done “off the cuff” for each patient.
For example, compare the statements: “The nurse practitioner and I saw the patient together” vs. “Both the nurse practitioner and I saw the patient.” These statements may sound identical, but the first one indicates that the physician and nonphysician practitioner were present at the same time, while the second makes no such assurance. The second statement could be used for both a visit that occurs simultaneously and one in which the professionals visited the patient sequentially.
If you are attempting to have one template statement that is useful in a variety of situations, you should clearly choose the second option. I prefer templates with more general statements that are guaranteed to satisfy the rule but are less likely to mischaracterize reality.
Best practices vs. requirements
I want to emphasize that I said “should” and not “must.” I often talk about the difference between “best practices” and “requirements.” I recently saw a consultant’s report that failed to grasp that important nuance. The review involved teaching physician services. The consultants were troubled by attestations such as “I saw the patient and agree with the resident’s note.” The consultants asserted an attestation must name the resident. They believe the attestation must include the date of the resident’s note. When I reached out, the consultants and I suggested we have a conversation before we have a mutual call with the client. They declined, insisting that they were comfortable with their analysis, and there was no need to discuss it.
While it is certainly possible that they are comfortable, I am quite confident that they are wrong. From a risk management standpoint, I would much prefer that an organization have a well-constructed attestation that applies broadly instead of relying on each professional to construct a perfect attestation for each encounter.
Careful wording
Small wording variations that are common in our everyday conversation can weaken documentation. Take the comment: “Dr. X saw the patient.” Did he or she examine the patient? Technically, we don’t know. Say a nonphysician practitioner wrote: “Dr. Y supervised my care.” Was he or she involved in the medical decision-making? Again, we don’t know.
To bill for a shared visit, the physician must either do the majority of the time or a substantive portion of the medical decision-making. The template should make that clear. A statement like: “Dr. Y was responsible for the medical decision-making” meets the requirement of the rule, as long as it is accurate.
Take the time to perfect a good statement that may understate, but will never overstate, the reality. A well-constructed broad statement is superior to relying on individual professionals casually trying to record what they did in each case.
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