College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP -

Make Me the Author function in the Epic Electronic Medical Record

The Make Me the Author (MMTA) function in the Epic ambulatory electronic medical record has been enabled as of Monday, August 23, 2010. MMTA generates a physician note consolidating both the resident/NPP note with an attending, without visible edits and corrections. An audit trail of the resident/NPP note is retained. The signature indicates MMTA has been used, appending "last edited by" in the signature block but does not print original author's name. When the original author is a Resident, Teaching Physician documentation requirements still apply. The Attending must continue to append his or her teaching physician attestation, describing his or her participation in the services. The attestation must appear in the final version of the note.

Limitations:

MMTA functionality is only available in the Epic Ambulatory application (it is not available in Inpatient). MMTA only works with a "pended" note. It does not work for closed notes, so it cannot be used for prior notes from the same patient, or a note from another patient. Medical Students, Non-physician practitioners, and Residents do not have access to this functionality.

MMTA has only been approved for use in notes that will be used as correspondence to physicians outside of our practice. Its purpose is to generate a "clean" consultation/referral note, without visible edits of the Resident's documentation.

Do NOT use MMTA for billable services when the Physician did not see and evaluate the patient personally, including the Primary Care Exception and "Incident to". These services must be submitted in the NPP billing number.

Future versions of MMTA will indicate previous authorship. Regularly scheduled audits will include review of the entire documentation trail and testing for the appropriate use of MMTA.

The attending, as always, is responsible for the entire content of his or her documentation and is personally responsible for its accuracy and medical necessity.

Any questions? The Office of Physician Billing Compliance contact information: (352)265-8359 or e-mail Nina Tarnuzzer (nwt@ufl.edu).

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