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Click here for more sample CPC practice exam questions and answers with full rationale

Surgical documentation question

I have a situation where two physicians performed a complex surgery. One was the primary surgeon, the other is the assistant surgeon. My problem is the only operative report was done by the assistant surgeon. He does list himself as the assistant surgeon in the dictation. There is no addendum by the primary surgeon, or his signature anywhere on the documentation. I’m fairly sure this doesn’t meet documentation requirements, but I can’t find anything written to back that up. The primary physician told me " the assistant did the dictation for both of us". Any guidance would be appreciated.

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