Teaching Physician Documentation Revised

Teaching Physician Documentation Revised

There’s been a change to teaching physician documentation rules, effective Jan. 1, for claims to Medicare. And, those changes are to the benefit of teaching physicians.

As explained in MLN Matters Number: MM10412 Revised:

The Centers for Medicare & Medicaid Services (CMS) is revising the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, to update policy on Evaluation and Management (E/M) documentation to allow the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

The Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, now specifies:

Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

On medical review, the combined entries in the medical record by the teaching physician and the resident constitute the documentation for the service; the combined documentation must support the medical necessity of the service.

Allowing a teaching physician to verify a student’s documentation, rather than re-document, “from scratch,” will save those providers time, but they must still be cautious to meet the teaching physician documentation rules. For example, the teaching physician must participate in the management of the patient: Documentation by the resident of the teaching physician’s presence and participation is not enough to establish such participation.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

2 Responses to “Teaching Physician Documentation Revised”

  1. Remote Billers says:

    This is nice information on Teaching Physician Documentation. I like these article. Thanks for sharing such important details for us.

  2. Phillip Talbert says:

    Must the teaching physician’s note (attestation) state that he preformed the exam or re-preformed it or is it assimed that he did because there are Exam elements in the note? Our teaching physicians are merely stating that they were present and agree with the residents note. Is this enough?

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