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Part B Insider (Multispecialty) Coding Alert

Teaching Physicians:

A Year Later, Coders Still Nervous About Documentation Rules

Published on Mon Feb 23, 2004

Documentation requirements changed, but performance requirements still strict

It's been more than a year since the Centers for Medicare & Medicaid Services loosened the reins on teaching physician documentation (in Transmittal 1780, November 2002). But while teaching physicians have gotten more laid-back about their documentation, coders and auditors still worry they're not documenting enough.

"Some of the compliance people are worried they're going to get trapped," says Jeff Linzer, an assistant professor with the division of emergency medicine at Emory University School of Medicine in Atlanta. "They're wanting the teaching physician to write more than what's required by Medicare for billing purposes."

But coders retort that some physicians have become too sloppy in adding to residents' documentation. They've come dangerously close to the sort of "rubber-stamp" phrases CMS says aren't OK in its instructions, such as "Agree with above" or "Seen and agree." Such "incredible shrinking documentation" has some coders worried.

"You no longer have to write the key portions of the history and physical," says Linzer. "The combination of  the teaching physician's and resident's notes determines the level of service."

It's important to be aware that the actual performance requirement for teaching physicians remains strict, says Bart Hershfield, president of CHECKCHART Template Documentation System in Wheeling, W.V., and associate director of the emergency department at Wheeling Hospital. Teaching physicians "have to personally see the patient, and they have to be involved in the key portion of the E/M services ," he says.

And their documentation must show that they personally saw and examined the patient and reviewed the resident's documentation, Hershfield adds. "Certainly the documentation's a lot less than it was." But the teaching physician may also want to write down more details than Medicare requires for billing, for medical-liability reasons.

For coders who remain concerned about the details of documenting inpatient or office E/M services in a teaching physician setting, Part B carrier HGSAdministrators has updated its guidelines:

  • A teaching physician must be "physically present" during critical or key portions of the resident's service, and must participate in the management of the patient.

  • The teaching physician's documentation may be "brief" and comment briefly on the key elements of medical decision-making. The teaching physician's and resident's documentation together will determine the level of E/M service.

  • If the resident examines the patient without the teaching physician present, the teaching physician should independently perform the key portions of the service, with or without the resident, and document this. Later, the physician and resident should compare notes.

  • Residents in graduate medical education programs that have received a "primary-care exception" can bill separately for lower- and mid-level E/M services. The teaching physician can't be supervising more than four residents at one time and must be available and review the resident's care.

  • For any time-based billing, such as critical care or prolonged services, the teaching physician must be present for the entire period of time for which the resident bills. The teaching physician must document time spent with the patient in detail. Time spent teaching can't be counted toward critical care services.

    Note: See the HGSA Billing Guide at www.hgsa.com/professionals/bguides/pf-teach.shtml.

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