Pulmonology Coding Alert

What to expect from your pulmonologist Now that you know when you can report an E/M service under the teaching physician rules, you should know what to look for in the pulmonologist's documentation.
 
To satisfy documentation requirements, your physician should either write a separate medical note, as in a nonteaching setting, or refer to the resident's note from the earlier visit, says Jillian H. Kuruc, MHA, CPC, CCS-P, a clinical technical editor with Ingenix Health Intelligence in Binghamton, N.Y.
 
When the TP refers to the resident's documentation, he or she may write, "I performed a history and physician 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," Kuruc says.
 
The medical documentation should include more than a review of the treatment plan and greeting the patient, Kuruc says.
 
To ensure that the physician thoroughly documented the visit, you should not submit documentation that includes only the following phrases:
   Agree with above.
   Rounded, reviewed, agree.
   Discussed with resident. Agree.
   Seen and agree.
   Patient seen and evaluated. Also, your pulmonologist should always use the personal pronoun 'I,' not the plural 'we,' when writing a medical note for an E/M service, Kuruc says. "The teaching physician must provide primary attestation of personal involvement" in the service, she adds.