American College of Physicians: Internal Medicine — Doctors for Adults ®

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Medicare updates billing rules for teaching physicians

In a clear win for internists, attendings do not need to repeat documentation already provided by residents

From the January ACP-ASIM Observer, copyright 2003 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: How have Medicare documentation rules changed for evaluation and management (E/M) services that are provided by residents and billed by teaching physicians?

A: The Centers for Medicare and Medicaid Services (CMS) 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. The revised regulations provide common scenarios instructing teaching physicians how to properly bill when residents are involved in providing E/M services. The regulations also give examples of acceptable and unacceptable medical record notations.

ACP-ASIM was directly involved in developing the revised regulations' documentation instructions and common scenarios. The College has worked with Medicare on this issue for the last eight years to make sure the regulations accurately reflect the teaching environment and don't burden teaching physicians with redundant documentation requirements.

Under the new regulations, Medicare auditors must consider the combined medical record entry of the teaching physician and resident when determining whether the documentation justifies the level of service the teaching physician billed.

The following scenarios help illustrate some of the changes.

Scenario 1

A teaching physician personally performs all the required elements of an E/M service without a resident present, or a resident may have independently performed some portion of an E/M service, such as taking a history.

When a resident does not make any notes about services provided, the teaching physician must document the E/M service as if he provided it in a non-teaching setting.

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. For payment, the composite of the teaching physician's entry and the resident's entry must support the medical necessity and level of service that the teaching physician is billing.

Here are examples of minimally acceptable medical record notations under the new regulations:

  • 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."

  • 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."

Scenario 2

The resident performs the required E/M service elements in the presence of or jointly with the teaching physician. 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. The teaching physician's note should reference the resident's note. For payment, the composite of the teaching physician's entry and the resident's entry must support the medical necessity and level of service that the teaching physician is billing.

Here are two examples of minimally acceptable medical record notations under the new regulations:

  • 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."

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

Scenario 3

The resident performs some or all of the required elements of an E/M service without a teaching physician present and documents the service. The teaching physician independently performs key portions of the service with or without the resident present, and, as appropriate, discusses the case with the resident.

In this instance, the teaching physician must document that he or she personally saw the patient, performed key portions of the service, and participated in managing the patient. The teaching physician's note should reference the resident's note. For payment, the composite of the teaching physician's entry and the resident's entry must support the medical necessity and level of service that the teaching physician billed.

Here are examples of minimally acceptable medical record notations under the new regulations:

  • 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 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: "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."

Q: What does Medicare consider unacceptable teaching physician documentation?

A: Documentation that fails to indicate that the teaching physician was present, evaluated the patient or had any involvement with the plan of care is unacceptable. Below are some examples of unacceptable documentation.

  • "Agree with above," followed by legible countersignature or identity;

  • "Rounded, Reviewed, Agree," followed by legible countersignature or identity;

  • "Discussed with resident. Agree," followed by legible countersignature or identity;

  • "Seen and agree," followed by legible countersignature or identity;

  • "Patient seen and evaluated," followed by legible countersignature or identity; and

  • A legible countersignature or identity alone.

Q: How must a teaching physician document an E/M service provided by a medical student?

A: A teaching physician or resident must be physically present when a medical student contributes to or participates in providing a billable service (other than when reviewing systems or family/social history, which are not separately billable). Medical student involvement must be in the presence of a resident in a service that meets Medicare requirements for teaching physician billing.

Students may document services in the medical record. When teaching physicians make their personal notes, they can refer to the student's documentation of review of systems and family/social history, but not the student's physical findings or medical decision-making. If the medical student documents E/M services, the teaching physician must verify and re-document the history of present illness as well as perform and re-document the physical exam and medical decision making.

The College's Practice Management Center (PMC) offers additional guidance. College members can access the PMC publication, "[M]What internists need to know about documentation for services provided by teaching physicians," online.

Brett Baker is a third-party payment specialist in the College's Washington office.

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