General Surgery Coding Alert

Documentation Requirements Ease for Teaching Physicians

Published on Sat Mar 01, 2003

By Eric Sandham, CPC

Under new Medicare rules, teaching physicians will find it easier to document services provided with residents and medical students. CMS will no longer require physicians to repeat services already provided by residents and instead will focus on the key elements of care.

No More History Repeating

Prior to the new guidelines (effective Nov. 22, 2002), Medicare required attending physicians to document the key elements of history, exam and medical decision-making (MDM) separately, in addition to noting their personal presence (or independent verification) and discussion of a resident's findings. The implication was that the teaching physician performed the complete service but did not duplicate the resident's note.

"The rules were created to prevent physicians from being paid twice for supervision of residents," says William Rogers, MD, chairman of CMS'Physician Regulatory Issues Team that guided the discussion of the new rules. Medicare Part Apays for resident supervision, while Part B reimburses for treatment of beneficiaries. In the past, Rogers says, physicians could sign off on a resident physician's care without ever seeing the patient. This is a problem if the teaching physician then bills Medicare Part B, a practice that led to the Physician at Teaching Hospital (PATH) audits of the last decade and settlements reaching as much as $30 million.

The new rules are more in line with the academic practice of medicine, in which a resident presents the case to an attending physician, who then confirms the key elements without repeating the entire history and exam. The essential element that teaching physicians must document under the new guidelines is their personal involvement in the key, critical portions of evaluating and managing a patient. The physician may then bill a level of service that reflects the combined cognitive work of both attending the patient and supervising the resident.

Medicare announced the new guidelines in CMS Transmittal 1780, which significantly changed section 15016 of the Medicare Carriers Manual. The transmittal states that faculty physicians must personally document at least that they tended to the patient personally or were physically present during the key or critical portions of the service when performed by the resident and that they participated in the patient's management.

Relieving teaching physicians of the requirement that they separately document the "key portions" of the history, exam and MDM reflects CMS'awareness that an attending physician's service to a patient includes both direct care and overall management of a healthcare team of residents, medical students and ancillary staff. Now teaching physicians must document only that they "personally saw the patient, personally performed the critical or key portions of the service, and participated in the management of the patient," according to the CMS transmittal.

Watch Your Words

Examples of acceptable documentation can shed some light on acceptable language. For instance, a common element of the acceptable documentation is using first-person pronouns and the active voice to show the teaching physician's presence and participation in the patient's management. For example, "I saw the patient ," "I was present ," "I reviewed " are suitable, whereas "Seen and agree" is not. The unacceptable documentation "does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care," according to CMS transmittal 1780.

Other examples of acceptable documentation include:

Initial visit with resident: "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."

Initial visit after resident service: "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note."

Follow-up visit with resident: "I saw the patient with the resident and agree with the resident's findings and plan."

Follow-up visit after resident service: "See resident's note for details. I saw and evaluated the patient, and agree with the resident's findings and plan as written."

Examples of unacceptable documentation still include "Agree with above," "Patient seen and evaluated" and "Discussed with resident. Agree."

Residents' Notes Will Matter More

Perhaps the greatest impact of the new regulations will be an increased dependence on residents'notes. With teaching physicians possibly writing less, a resident's incomplete documentation of history, exam and MDM could have a negative effect on the level of service you can substantiate. Graduate Medical Education programs should consider incorporating coding and compliance education along with clinical competencies, and faculty will have to pay closer attention to what the resident has written when selecting an E/M code. For example, lack of a family history could technically mean that you can report only a Level I initial hospital visit (99221), even if all other elements of the service are comprehensive.

Teaching physicians have asked whether the standard language of the examples means that they can now use "rubber stamps" to certify their services to patients. The regulations seem to exclude this practice because "Documentation may be dictated and typed, hand-written or computer-generated, and typed or handwritten," according to CMS. This seems to allow for some form of template and electronic medical record systems, however. Other fundamental documentation standards, such as legibility of note with signature and date, still apply.

The new regulations clarify the current rules regarding residents'documentation, stating, "Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing."

This means that teaching physicians may bill for services the medical student performs in their personal presence, including both E/M services and procedures. "We cannot teach medical students if all they can do is watch," Rogers says. As before, medical students may also scribe for the faculty physician's services, if such is clearly noted. Teaching physicians may bill for a student's participation under a resident's supervision if the faculty physician is present for the critical and key portion of the service. However, if the teaching physician is not personally present, only a medical student's review of systems and past medical, family and social history may be incorporated.

Note: The complete revised guidelines, including additional acceptable documentation samples, are available at http://cms.hhs.gov/manuals/pm_trans/R1780B3.pdf.