Orthopedic Coding Alert

Teaching physicians, take note: Don't rely on residents to complete your documentation for you. Your reimbursement hinges on complete documentation - yours and the resident's.
 
Last November, the Department of Health and Human Services released Medicare Transmittal 1780, which relaxed documentation requirements for E/M services that residents render and teaching physicians (TPs) bill. The new requirements do not, however, mean that teaching physicians can relax by simply stamping "Concur with resident" on every chart.
 
The new requirements allow physicians to document that they saw and evaluated the patient and that they agree or disagree with the resident's findings, says Mike Lemanski, MD, a physician at Baystate Medical Center, a large teaching hospital with an E/M residency program of 36 residents. In other words, "TPs do not need to repeat documentation already provided by the resident." In the past, TPs had to document the key elements of the E/M evaluation: the history, physical exam and medical decision-making, Lemanski says.
 
Although physicians will benefit from these guidelines, you should be aware of some ambiguous documentation practices that could get your practice into hot water. First, make sure that your physicians meet the requirements stated directly in the transmittal (excerpted on page 69).
 
Define the Exam's 'Key' Portion CMS mandates that teaching physicians must only document "that they performed" or were "physically present" during the key portions of the E/M service. Despite the new documentation guidelines, however, TPs must still be directly present for "key" or "critical" portions of E/M exams and must examine the patient and review and discuss the resident's plan of care.
 
The transmittal indicates that the TP should determine which portion of the exam he or she considers key or critical. "The guidelines clearly state that if the key portion cannot be defined, the teaching physician must be present for the entire service," says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc., a healthcare reimbursement consulting firm in Dallas, Ga. "Therefore, any 'key portion' requires a specific, written definition," Parman says.
 
This does not mean that the TP can breeze in during the key portion and leave the room immediately afterward. "The teaching physician is reimbursed for direct patient services, not for the teaching services provided to the resident/teaching facility," Parman says. "If the resident sees the patient, performs all elements of an E/M and documents his or her findings, the TP must review all data, discuss the information with the resident, repeat key portions (and list specifically what those are) and dictate his or her own note."
 
Don't Accept Shrinking Notes Some orthopedic practices report that their TPs' documentation shrinks a bit every month as they rely on the new documentation regulations to coast them through potential audits. [...]