Neurosurgery Coding Alert

By Eric Sandham,CPC Teaching physicians will find documenting services they provide with residents and medical students significantly easier under new Medicare guidelines effective Nov. 22, 2002. CMS will no longer require physicians to repeat services already provided by residents and instead focus on the key elements of care. No More Redundant Services Under the prior rules, Medicare required attending physicians to document separately the key elements of history, exam and medical decision-making (MDM), in addition to noting their personal presence (or independent verification) and discussion of a resident's findings. The implication was that the teaching physician was performing the complete service but not duplicating the resident's note.

"The rules were created to prevent physicians from being paid twice for supervision of residents," says William Rogers, MD, chair of CMS Physician Regulatory Issues Team that guided the discussion of the new rules. Medicare Part A pays for resident supervision while Part B reimburses for treatment of beneficiaries. In the past, he notes, physicians might 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 for the same service, a practice which led to the Physician At Teaching Hospital (PATH) audits of the last decade and settlements up to $30 million. The new rules are more in line with the academic practice of medicine, in which a resident typically 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. When meeting this requirement, they may bill a level of service that reflects the combined cognitive work of both attending and resident supervision.

Medicare announced the new guidelines in CMS Transmittal 1780, which significantly changed section 15016 of the Medicare Carriers Manual. It states that faculty physicians must personally document at least that they performed the service or were physically present during the key or critical portions of the service when performed by the resident, and that the teaching physician 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." Watch Your Words Several examples of acceptable and [...]