ED Coding and Reimbursement Alert

Use these expert tips for surefire documentation Knowing how and when to report evaluation and management services under the teaching physician rules launches you over one hurdle - but unless you also know what to look for in the physician documentation, you'll be back at square one.
 
To satisfy documentation requirements, the physician should either write a separate medical note, as in a non-teaching setting, or refer to the resident's note from the earlier visit, says Jillian H. Kuruc, MHA, CPC,
CCS-P, a clinical technical editor with Ingenix Health Intelligence in Binghamton, N.Y.
 
When the TP refers to the resident's documentation, he or she may write, "I performed a history and physical exam 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," Kuruc says.
 
The medical documentation should include more than a review of the treatment plan and greeting the patient, she says. To ensure that the physician thoroughly documented the visit, remember to avoid submitting reports to payers with the following phrases and documentation:

  Agree with above.
  Rounded, reviewed, agree.
  Discussed with resident. Agree.
  Seen and agree.
  Patient seen and evaluated.
 
Also, your ED doctor should always use the singular personal pronoun "I," not the plural "we," when writing a medical note for an E/M service, Kuruc says. The TP should prove that he or she directly managed the patient's care and supervised the resident's work.