General Surgery Coding Alert

Question: Does an attending physician have to be in the hospital to bill for any service performed by a resident? If so, what happens if the resident performs a consult on day one at 11 p.m. and no attending physician is present? Can the attending surgeon bill for the consult and date the bill for day two, when he actually reviews the data, even if the consult is dictated and dated day one? Or should the resident be instructed to wait to dictate the consult until the next day, when the attending surgeon is present?

Louisiana Subscriber  
Answer: The resident must dictate what he or she did on the day it was done. If the attending physician isnt there, the resident cant bill, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. However, the consultation can be billed on the day the teaching physician visits the patient and documents his or her portion of the service.
 
Section 15016 of the Medicare Carriers Manual specifically states that physician services furnished in a teaching setting should be paid under the physician fee schedule only if:
 
1. The services are personally furnished by a physician who is not a resident, or
 
2. The services are furnished jointly by a teaching physician and resident or by a resident in the presence of a teaching physician.  
The teaching surgeon does not have to be in the same room when the resident evaluates the patient, but must provide personal services to the patient before the service is billable. In other words, the physician at some time must have a personal encounter with the patient. The teaching physician should create his own documentation, referencing the residents documentation as appropriate. The service is not billable until the teaching physician does this.
 
To bill for a consultation with a new or established patient performed by a resident, the surgeon has to review the residents note, repeat the key portions of history and examination and confirm or modify the assessment and plan (medical decision-making). In general, all teaching-physician documentation must address the key elements required by the code.
 
Medicare guidelines also state:
 
A personal notation must be entered by the teaching physician documenting his or her participation in the three key components of these services. ... If the teaching physician is repeating key elements of the service components obtained previously and documented by the resident (e.g., 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 [...]