Inpatient Facility Coding & Compliance Alert

Question: If no linking statement by the attending physician is present, which part of the resident’s note may be used in leveling an E/M Service for a Medicare patient seen in the ER?

Virginia Subscriber

Answer: There has to be a linking statement along the lines of those pasted below from Transmittal 2303. Additionally, though the ROS and Past/Family/Social History may be gathered by anyone they must be reviewed and confirmed by the physician.

Following are examples of minimally acceptable documentation from CMS:

• “I performed a history and physical examination 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.”
• “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
• “I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.”
• “I was present with the 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.”
• “I saw the patient with the resident and agree with the resident’s findings and plan.”
• “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
• “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”
• Note: In a facility setting, a physician or practitioner can only code and bill for what he or she personally performs, though the teaching physician/resident situation is a special circumstance where this type of “service oversight” is acceptable.