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. The statement "I was present with the resident during history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note" is now acceptable but could too easily be shortened in a busy hospital to "Discussed with resident. Agree." If you see TP documentation that states the latter, don't report the service until you have more documentation. CMS will not consider the shortened statement acceptable.
 
Inform your teaching physicians that when they perform E/M services, their documentation should demonstrate that they examined the patient (independently or with the resident); that they reviewed, discussed and agreed with the findings and plan of care; and note any exceptions or changes between the resident's documentation and the TP's.
 
In addition, be sure to avoid rubber stamps with standard lines such as "Agree with above" or "Patient seen and evaluated. Agree with resident," says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco.
 
Sandham suggests that TPs use the first-person and active voice to show that they participated in the patient management. Review the following two scenarios to ensure that your physicians and you share the same documentation expectations. After all, if you don't submit the correct documentation, you're not able to secure all of the money that your practice deserves.

Scenario #1

Case: A resident sees a 48-year-old man who fell off a ladder and landed on his left shoulder. The man was unconscious when admitted to the hospital. When the patient awakens, the resident examines him, reads the x-ray films and diagnoses the patient with a dislocated shoulder (831.02). The teaching physician then examines the patient and confirms the resident's findings.

Documentation You Should Expect: "History: Refer to the resident note. The history was reviewed with both the resident and the patient, and I was present for the physical examination. I discussed the findings with the resident and agree that the patient has a posterior shoulder dislocation. I agree that the patient requires closed manipulation and splinting."
 
The TP reports this service as a subsequent inpatient encounter (99231-99233).

Scenario #2

Case: The resident sees a 7-year-old girl who presents to the ED with severe wrist pain following a bicycle accident. The resident performs an examination and orders a wrist x-ray. He reviews the films and diagnoses a sprained wrist (842.00). The attending orthopedist reviews the x-ray and notes a hairline fracture in the patient's scaphoid (814.01). In this case, the TP does not agree with the resident's assessment and plan.

Documentation You Should Expect: "History: Refer to the resident note. The history was reviewed with both the resident and the patient, and I observed the resident as he performed the physical examination. I have reviewed and discussed the findings with the resident. I believe the child has a fractured scaphoid and agree that the patient's wrist must be immobilized, but I recommend a gauntlet cast rather than the splint that the resident recommended."
 
Because an ED physician initially saw the patient and subsequently requested the TP's opinion, the TP should report an outpatient consultation code (99241-99245).

Residents' Notes Should Sparkle

Because the new regulations allow TPs to document less, residents' notes should be more thorough than ever before, Sandham says. "For example, a lack of family history could technically mean that you can report only level-one initial hospital care (99221) even if all other elements of the service are comprehensive."

Because the TP's reimbursement now relies on the resident's documentation, the TP should ensure that the resident documents the appropriate history, exam and medical decision-making elements.