ED Coding and Reimbursement Alert

Question: When seeing a Medicare patient, does the history of present illness (HPI) have to be documented by the attending physician when that doctor is supervising a resident in a teaching setting? And, do all separately billable procedures need to be documented by the teaching physician supervising the resident?

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Answer: At issue in these questions is how complete the documentation by an attending physician should be, especially concerning a Medicare patient.

For example, is it enough for the attending physician to simply write that he or she has reviewed the residents HPI and agrees with it? When all the elements of the history and physical are obtained in the presence of, or jointly with, the teaching physician, the HPI can be gathered by the resident, says Palmerton. But, she stresses, at minimum, the attending doctor must confirm each component of the residents documentation and his or her presence during the service.

A combination of the entries must substantiate the level of service required for treating the patient. If the resident performs the services independently, the teaching physician should repeat the key elements. These elements can be discussed with the resident either before or after the teaching doctors personal service. It is truly best for the teaching physician to document his or her service, and bill according to that information, she recommends.

Considering the Health Care Financing Administrations effort to crack down on Medicare fraud and abuse, Palmerton says providers may want to err on the side of caution, and have the attending physician fully document and restate the HPI in his or her own words, and sign the chart.

In an academic setting, she adds, the only codes that can be billed without the preceptor being physically present for the critical components of the visit are 99211-99213, which are the lower-level E/M codes for established patients.

Also, the teaching doctor must agree or disagree with the residents interpretation in writing, and sign the report after doing his or her own personal review, she says. Again, when dealing with a Medicare patient, document it fully, she recommends.