Department of Neurology

TEACHING PHYSICIAN:

DOCUMENTATION REQUIREMENTS

FOR E/M SERVICES

The Centers for Medicare and Medicaid Services (CMS) recently revised its documentation requirements to clearly state that teaching physicians do not need to repeat documentation already provided by a resident for E/M services. Medicare rules permit a teaching physician to bill based on the combination of the resident's and teaching physician’s documentation for a specific service. The teaching physician must clearly convey that he/she saw the patient and participated personally in the patient's care up to the level of E/M service billed. Participation is defined as either personally performing the key portions of the service or observing the resident perform the key components. In all cases, the teaching physician must personally document his/her presence and participation in the E/M services. When a resident is involved in a service, the documentation provided by the teaching physician is intended to supplement the more detailed documentation for the same service provided by the resident, and may be limited to brief, summary comments of the most relevant patient information which revise or confirm the resident's history, physical exam, and substantiate the level of service.

The teaching physician must always write a statement establishing his/her presence. Using personal pronouns and phrases (e.g., "my exam" or "reviewed with patient" or "patient seen and/or examined") will convey presence. When a resident has written notes, the teaching physician's note may reference them. The teaching physician must document that he or she performed key portions of the service and that he or she was directly involved in managing the patient. If the resident performs the required E/M service elements in the presence of or jointly with the teaching physician, and the resident documents the service, the teaching physician must document that he or she was present when key portions of the service were performed and that he or she was directly involved in managing the patient. For payment, the composite of the teaching physician's entry and the resident's entry must support the level of service that the teaching physician is billing.

Examples of Minimally Acceptable Documentation
 

Admitting note: "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care."

Initial visit: "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs."

Initial or follow-up visit: "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."

Initial or follow-up visit: "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note."

Follow-up visit: "Hospital day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note."

Follow-up visit: "Hospital day #5. I saw and examined the patient. I agree with the resident's note except the heart murmur is louder, so I will obtain an echo to evaluate."

Follow-up visit: "I saw the patient with the resident and agree with the resident's findings and plan."

Follow-up visit: "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plans as written."

Follow-up visit: "I saw and evaluated the patient. Agree with resident's note but lower extremities are weaker, now 3/5; MRI of L/S spine today."

Examples of Unacceptable Documentation
 

"Agree with above"

"Rounded, Reviewed, Agree"

"Discussed with resident. Agree"

"Seen and agree"

"Patient seen and evaluated"

Simply countersigning the resident’s note

Medical Student Documentation

The only documentation by medical students that may be used by the teaching physician is their documentation of the review of systems (ROS) and past medical, family and social history (PFSH). The teaching physician may NOT refer to a medical student's documentation of physical exam findings or medical decision-making in his/her personal note. The teaching physician must verify and re-document the history, exam and medical decision-making activities.

Other than the review of systems or past/family/social history, a teaching physician or resident must be physically present when a medical student contributes to or participates in providing a billable service. Medical student involvement must be in the presence of a resident in a service that meets Medicare requirements for teaching physician billing.

Teaching Physician Requirements
 

The teaching physician in whose name the payment is sought must:

• not supervise more than 4 residents at any given time

• direct the care from such proximity as to constitute immediate availability

• have no other responsibilities at the time of the service for which payment is sought

• assume management responsibility for patients seen by resident

• ensure that the services furnished are appropriate

• review with each resident during or immediately after each patient’s visit the history, examination, diagnosis, and record of tests and therapies; and document the extent of his or her own participation in the review and direction of the services furnished to the patient.