E/M Documentation for Teaching Docs Changes July 1, 2019

There is a change in Medicare policy forthcoming regarding evaluation and management (E/M) services documentation requirements for teaching physicians.
It is important to train teaching physicians, residents, and nurses who document E/M services of all changes to be implemented on July 1, 2019.
To quote from the MLN article MM11171: The following provides these policy clarifications:

• For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate: 1) that the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and 2) the participation of the teaching physician in the management of the patient.
• The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes made by the notes in the medical records made by physicians, residents, or nurses.

What Is CMS Telling Us?

In other words:

1. The teaching physician’s participation may be documented by either the teaching physician, resident, or nurse as of July 1, 2019. This is a loosening of the current requirements, as we now may only use the teaching physician’s documentation of the participation. Documentation by the resident or the nurse of the teaching physician participation currently does not count in current documentation. But as of July 1, 2019, the resident’s and nurse’s documentation of the teaching physician’s participation will be counted.
2. Current attestations may not be used, as they do not include the “extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary.” This means that current attestations will need to be extended to include free text that is specific to the beneficiary encounter, which will be different for each beneficiary.

In other words, while CMS simplified E/M documentation requirements for teaching physicians, they complicated attestation requirements.
Read CMS transmittal  CR111171  for complete details.
Related reading:
Teaching Docs Have a New Way to Document E/M

• Author
• Recent Posts

Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, COC, CENTC, CPC-P, CPC-I, CPCO, CMCS, is CEO of CRN Healthcare Solutions and formerly owned a medical billing company. Cobuzzi is a subject matter expert in otolaryngology coding. She provides litigation support as an expert witness for providers and payers and often presents for many local and national organizations. She is also a consulting editor for AAPC’s Otolaryngology Coding Alert newsletter. In 1999, Cobuzzi was named AAPC’s Networker of the Year, and she is a past member of the National Advisory Board. She is one of four founding members of the Monmouth/Ocean, N.J., local chapter and is still active with the chapter.

Latest posts by Barbara Cobuzzi (see all)

• Coding Uncertain Lesion Excisions With Certainty - August 1, 2022
• CDI Tips for Diagnostic Endoscopies - May 2, 2022
• Medicare Telehealth Coding as of April 30 - May 1, 2020