Neurosurgery Coding Alert

Question: My neurosurgeons work at a teaching hospital. What should I look for in the documentation to make sure the teaching physician has satisfied the Medicare supervision requirements?


New York Subscriber

Answer: Medicare requires that your teaching physician (TP) either see the patient solely or, if in conjunction with the resident, perform the key/critical aspects of the patient's evaluation and participate in the management of the patient.

When your TP refers to the resident's documentation, he may write, -I performed a history and physical exam 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.-

Pointer: Your neurosurgeon should include more than a review of the treatment plan and greeting the patient in his medical documentation. Instruct your physicians to steer clear of the following phrases in their documentation:
- Agree with above.
- Rounded, reviewed, agree.
- Discussed with resident. Agree.
- Seen and agree.

Phrases such as these don't provide enough information to the insurance carrier. You should also advise your neurosurgeons to use the first-person pronoun in their documentation, which helps prove that they directly managed the patient's care and supervised the resident's work. For example, -I adjusted the halo- indicates who did the work, whereas payers could interpret -Adjust halo- as orders to a resident.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandhusen, CHC, CPC, director of compliance for the Columbia University department of surgery.