ED Coding and Reimbursement Alert

The new teaching physician guidelines will reduce, but not eliminate, teaching physician E/M documentation. Read through these tips and scenarios to make sure your physicians and you see eye-to-eye about documentation expectations. After all, if they're not sending in the correct documentation, you're not able to secure them the money they deserve.

The guidelines "decrease some of the documentation burden for teaching physicians in any setting, including the ED," says Susan Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis. But the rules don't eliminate the need to review the limited but necessary documentation requirements.

Turney emphasizes that physicians must be taught what qualifies as acceptable documentation. The transmittal scenarios help clarify what kind of documentation Medicare permits. (Turn to page 7 to see the transmittals'key scenarios.)

Inform your physicians that when you're coding E/M services, your teaching physician's documentation should, according to CMS'scenarios, document that he or she examined the patient (independently or with the resident); document that he or she reviewed, discussed and agreed with the resident's findings and plan of care; and note any exceptions or changes, summarizes Jeff Linzer, MD, MICP, assistant professor of pediatrics and emergency medicine at Emory University.

In other words, the TP no longer has to separately document the three key portions of history, physical exam and medical decision-making, Linzer says. Physicians no longer have to write out the plan of care.

Below, Linzer offers three scenarios to guide you through the new documentation requirements that dictate your coding. Use these scenarios and the ones in the CMS transmittal to ensure you have sufficient documentation from your physicians to report the E/M level of service deserved.

Case: Aresident sees a 48-year-old man with chest pain and starts an "r/o MI" workup. The patient is presented to the teaching physician, who examines and confirms the resident's findings.

Documentation You Should Expect: The TPhas written in the medical record, "I have seen and examined the patient and have reviewed Dr. X's notes. I agree with the resident's finding and plan." This minimal documentation is now acceptable. Under the old guidelines, the teaching physician would have also had to write what he or she considered the "key" portions of the history and physical, and write up an assessment and plan of care, Linzer says.

Case: Aresident sees a 7-month-old girl who presents with wheezing, fever and URI symptoms. The resident orders an albuterol treatment, steroids and a chest x-ray. The patient is presented to and examined by the TP. The attending physician, in this case, does not agree with the resident's assessment and plan.

Documentation You Should Expect: "I saw and evaluated the patient seen by Dr. A. I have reviewed and discussed the findings with the resident. I believe the child has bronchiolitis and agree with the basic plan but will defer the steroids and chest x-ray at this time."

Case: Aresident and teaching physician jointly see a 16-year-old female for back pain, fever and vaginal discharge. The TPis with the resident when the history and physical are done. They review the findings and agree on the plan.

Documentation You Should Expect: The teaching physician's note could state, "I was present with Dr. Y during the history and physical exam. We discussed the case, and I agree with the findings and plan as documented in the resident's note."

As a final word to the wise, remember that while Medicare is the trendsetter for reimbursement, not every carrier follows its determinations.

"Always check with your payers ahead of time to see what rules they apply for services provided in the teaching setting," Linzer says.