ED Coding and Reimbursement Alert

Question: What should I look for in the documentation to make sure the teaching physician (TP) has satisfied the Medicare supervision requirements?

Kentucky Subscriber

Answer: Medicare requires that the teaching physician either see the patient solely or, if in conjunction with the resident, perform the key/critical aspects of the patient's evaluation and participate in the management of the patient.
 
Example: When the TP refers to the resident's documentation, he 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."
  
Hint: The medical documentation should include more than a review of the treatment plan and greeting the patient. To ensure that the physician thoroughly documented the visit, remember to steer clear of 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.
 
Smart idea: Have the ED doctor write "I," not "we," when documenting a medical note for an evaluation and management service. The TP should prove that he directly managed the patient's care and supervised the resident's work, and using "I" helps indicate that supervision to the payer.

 - Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI and ED billing company in Stoneham, Mass.