Wiki documentation requirements are for attendings when they supervise residents

[kviolet]

I was hoping you would provide some clarification about what the documentation requirements are for attendings when they supervise residents- in terms of being able to bill optimally for a visit.

The requirements vary based on Level of Care?
If so, please outline what exactly elements are needed in the attending note specifically in order to bill the following levels. Also- please specify what elements need to be included in the resident note in order minimize what the attending needs to document in their note.

SO- for example- for a Level 4 visit if the resident writes a complete H&P, completes a full review of systems and physical exam which includes every organ system; and completes family history, past medical history and social history. If the resident also documents their assessment and plan, what specifically needs to be included on the note written by the attending in order to bill.

Level 3
Level 4
Level 5

 

[kak6]

Teaching Physician Documentation:
Source: CMS

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E/M Services
[FONT=Calibri,Calibri][FONT=Calibri,Calibri] Attending physicians must evaluate all patients when teaching[/FONT][/FONT]Residents [FONT=Calibri,Calibri][FONT=Calibri,Calibri]are involved in the care.
[/FONT][/FONT] Services are assigned to the teaching physician when the following documentation is provided;

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I saw and evaluated the patient. Discussed with resident and agree with the resident’s findings and plan as documented in the resident’s note. I was personally present for the key portions of any procedures. I have documented in the chart those procedures where I was not present during the key portions.
My personal findings are…


Critical Care:

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Only time personally performed and documented by the teaching physician can be counted and billed for critical care.

Procedures:

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The attending needs to be present during the key portion of procedures in order to bill for the procedure.

Examples of acceptable resident note:
[FONT=Arial,Arial][FONT=Arial,Arial] "I performed a history and physical examination of the patient and discussed management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care. Any areas of disagreement are noted below. I was personally present for the key portions of any procedures. I have documented in the chart those procedures where I was not present during the key portions".

Examples of unacceptable teaching physician documentation include:
[FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]"Agree with above" followed by legible countersignature or identity
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]"Rounded, Reviewed, Agree" followed by legible countersignature or identity
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]"Discussed with resident. Agree" followed by legible countersignature or identity
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]"Seen and agree" followed by legible countersignature or identity"
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]Patient seen and evaluated" followed by legible countersignature or identity
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]A legible countersignature or identity alone
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]"I reviewed the resident’s note and agree with the documented findings and plan of care" [/FONT][/FONT]
[FONT=Calibri,Calibri][FONT=Calibri,Calibri] Such documentation is not acceptable, because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.

Examples of minimally acceptable documentation include:
[FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]"I performed a history and physical examination of the patient and discussed his management with the resident."
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]"I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."
[/FONT][/FONT][FONT=Wingdings,Wingdings][FONT=Wingdings,Wingdings]  [/FONT][/FONT][FONT=Calibri,Calibri][FONT=Calibri,Calibri]"I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs." [/FONT][/FONT]
[FONT=Calibri,Calibri][FONT=Calibri,Calibri] On medical review, the combined entries into the medical record by the teaching physician and the resident constitute the documentation for the service and together must support the medical necessity of the service.
Source: [FONT=Arial,Arial][FONT=Arial,Arial]www.[/FONT][/FONT]cms[FONT=Arial,Arial][FONT=Arial,Arial].gov/MLNProducts/downloads/gdelines[/FONT][/FONT]teach[FONT=Arial,Arial][FONT=Arial,Arial]gresfctsht.pdf [/FONT][/FONT]
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[FONT=Arial,Arial][FONT=Arial,Arial]I hope this helps clear up questions and you can go to CMS site for more information than you ever wanted to know ....
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