In the Emergency Department, when a patient arrives in arrest, minds race, fingers fly and the right procedures get accomplished in order to save a life. In the Operating Room, when a branch of the superior mesenteric artery gets away, a finger is slapped on the bleeding vessel, an order gets issued and the other hand goes out for the hemostat.
Physicians usually react appropriately and good patient care is provided.
Unfortunately, this mind-set does not always work when it comes to documenting and billing for the services provided. Medicare and other payors realize that physicians work to treat the patient, often failing to document everything they do in the Medical record. In the office or on rounds, physicians are often met with requests for treatment or for studies to be done, whether by nurses, physician extenders or the patients themselves. Whether in the office or in the hospital, the primary physician is the Captain of the Ship and is responsible, from a financial as well as from a liability perspective, for knowing his patient's status. In case of a consultant, if an intervention is suggested for a very specific condition, the total situation is still under the control of the primary physician.