Internal Medicine Coding Alert

Internists who work in the teaching environment will now find it easier to document E/M encounters that also involve a resident.

CMS recently clarified and relaxed its policies for the academic setting, specifying that teaching physicians do not have to repeat documentation provided by the resident and giving specific examples of acceptable and unacceptable documentation.

"For those who work in the teaching setting, it's a really big deal," says Brett Baker, third-party payment specialist for the American College of Physicians-American Society of Internal Medicine in Washington, D.C.

In years past, the U.S. Health and Human Services Department's Office of Inspector General (OIG) had questioned the adequacy of documentation provided by some teaching physicians. This prompted many compliance officers to require teaching physicians to extensively document encounters involving both a resident and a teaching physician.

"The compliance people erred on the side of caution," Baker says.

CMS' changes are outlined in CMS Transmittal 1780, which spells out documentation requirements for the resident and the physician and makes it clear that the teaching physician doesn't have to redo documentation provided by the resident.

"The sum of the documentation provided by the resident and the teaching physicians constitutes a complete note," Baker says.

Teaching physicians must do more than simply sign off on the resident's documentation, however. Such notes as "Agree with above," "Rounded, Reviewed, Agree," "Patient Seen and Evaluated" or simply writing a legible countersignature to the resident's note is unacceptable "because the 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," CMS says in Transmittal 1780.

Coders should use the combined documentation of the doctor and the resident to determine the appropriate E/M code, the transmittal notes.

The transmittal also clarifies policies for services involving students, and it addresses other issues related to academic centers.

This is the first time CMS has specified what constitutes minimally acceptable documentation and given examples of unacceptable documentation in the teaching environment, Baker says.

You can view Transmittal 1780 on the Web at http://www.cms.hhs.gov/manuals/pm_trans/R1780B3.pdf.