ED Coding and Reimbursement Alert

Question: We are a teaching hospital that trains residents in emergency medicine. When a resident and staff physician treat a Medicare patient, we get dictation from both. Is it necessary, according to Medicare guidelines, that the staff dictation be able to stand alone for coding purposes or can the physician just refer to the residents dictation for better details on the history of present illness or review of symptoms?

Wisconsin Subscriber
 
Answer: The Medicare Carriers Manual (MCM) 15016, Supervising Physicians in a Teaching Setting, states: Initial Hospital Care, Emergency Department Visits, Office Visits for New Patients, Office Consultations and Hospital Consultation -- a personal notation must be entered by the teaching physician documenting his or her participation of the three key components of these services [i.e., history, examination and medical decision-making] as required by CPT and demonstrating the appropriate level of service required by the patient.
 
If the teaching physician is repeating key elements of the service components obtained previously and documented by the resident, i.e., the patients complete history and physical examination, the teaching physician need not repeat the documentation of these components in detail. Rather, the documentation of the teaching physician may be brief summary comments that relate to the residents entry and confirm or revise the key elements defined for the purpose of this section as:
 
relevant history of present illness and prior diagnostic tests;
 
major finding(s) of the physical examination;
 
assessment, clinical impression or diagnosis; and
 
plan of care.  
Therefore, the documentation of the key elements may be satisfied by combining entries into the medical record made by the resident and the teaching physician. Basically, should the level of the E/M service ever be questioned, Medicare will consider both the teaching physicians and residents documentation in determining if the key components of history, exam and MDM are met. If both the resident and the attending physician dictate the patients visit, how is the attending to know what the resident recorded to agree with it or add to it? In that case, it would be better if the attending dictated the entire note to ensure adequate information for billing. If that is not possible, consider having the resident write his or her note so the information is available to the attending.