I am from South Dakota and most of the time our PAs will see the new patients. After our PAs have taken most of the HPI and exam, the Dr will then go in the room and decide on a plan. The PA dictates the encounter and in the MDM says Patient was seen by both myself and Dr. _____ on today’s visit. And then dictates if the patient will be started on a med, surgery, or any work up. Is this enough information to bill under the drs name for medicare patients?

Here is an example for MDM that was dictated by a PA

IMPRESSION:
1. Painless gross hematuria.
2. History of recurrent urinary tract infections.

RECOMMENDATIONS/PLAN: Patient was seen by both myself and Dr. _____ on today’s visit. We discussed today with ______ the process of finishing her hematuria workup which include cystoscopy with bilateral retrogrades and bladder washings under MAC anesthesia. This will be accomplished in our office. She will have preoperative H&P as well.

Then this is documented by dr.

I have examined and interviewed the patient and confirm the pertinent findings. I have discussed the case with _____, PA and agree with the pertinent findings and plan.