ED Coding and Reimbursement Alert

ED Coders,Expect Less Documentation from Your Physicians

Published on Sat Feb 01, 2003

Last November, the Department of Health and Human Services released a Medicare transmittal relaxing documentation requirements for E/M services rendered by residents and billed by teaching physicians.

The guidelines are a "big deal" for emergency departments, says Mike Lemanski, MD, at Baystate Medical Center, a large teaching hospital with an E/M residency program of 36 residents.

"There is no question that these clarifications to the teaching physician rules are extremely important to any ED," echoes Robert Polglase, MD, JD, CEO of Stratagem Group Inc. in Augusta, Ga. Many emergency departments have not realized the impact these rules could have on E/M coding, so we're here to spread the news.

In minimizing documentation requirements for TPs, the guidelines will definitely impact coding in the ED, decreasing redundant documentation time and increasing physician productivity which means you'll see more resident handwriting and, perhaps, more physician bills.

Read on to get an in-depth look at these regulations, and inform your office: Though physicians should benefit from these guidelines, you need to be aware of some ambiguous documentation practices that could get your practice in hot water.

Relaxed Physician Documentation Requirements

Medicare Transmittal 1780 is influential because it minimizes the teaching physician documentation requirements for E/M services rendered by the resident. So, coders, expect less documentation for E/M services.

The new requirements allow physicians simply to "state" that they saw and evaluated the patient and that they agree or disagree with the resident's findings, Lemanski says. In other words, "TPs do not need to repeat documentation already provided by the resident." In the past, TPs had to document the key elements of the E/M evaluation: the Hx, PE, and MDM, Lemanski says.

You should make sure your physicians meet the requirements stated directly in the transmittal excerpt below:

1. Evaluation and Management (E/M) Services: For a given encounter, the selections of the appropriate level of E/M service should be determined according to the code definitions in the American Medical Association's Current Procedural Terminology (CPT) and any applicable documentation guidelines.

For purposes of payment, E/M services billed by teaching physicians require that they personally document at least the following:

a. That they performed the service or were physically present during the key or critical parts of the service when performed by the resident; and

b. The participation of the teaching physician in the management of the patient.

When assigning codes to services billed by teaching physicians, reviews will combine the documentation of both the resident and the teaching physician.

Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician.

On medical review, the combined entities 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.

According to the transmittal, teaching physicians must only document "that they performed" or were "physically present" during the key portions of the E/M. The new regulations suggest that one simple line of confirmation will suffice, Lemanski says, so you may not need to request more information from the physician if one line is all you see.

However, remember to remind your physicians that to be paid, they must still be directly present for "key" or "critical" portions of the evaluation and management exams, says Jeff Linzer, MD, MICP, assistant professor of pediatrics and emergency medicine at Emory University. Linzer downplays the impact of the new rules for this reason, forecasting "little direct impact" on EDs. Even though you'll see less written information from physicians, their presence is still required for key portions of the exam, and they are still required to examine the patient, and review and discuss the resident's plan of care, Linzer says. The TPs will still determine the key or critical parts of service, he adds.

More Codes, Reports and Resident Charts

Expect to report more codes for your teaching physicians, code out a higher number of claims, and interpret more resident charts.

More codes for more reimbursement. You may now be able to apply codes for those E/M services that didn't warrant them before due to insufficient documentation or apply higher-level codes for more reimbursement. The teaching guidelines indicate a "significant easing on the regulatory burden" now weighing down physicians who teach residents, Polglase says. The easing requirements mean insufficient documentation may no longer block deserved reimbursement.

More claims to report. The regulations will decrease the time physicians spend meeting documentation requirements, and plausibly increase the time they have for patients. As a doctor, Lemanski reports he sometimes spends as much time documenting as physically seeing patients, so he is "thrilled to death" about the new regulations because they free him from bureaucratic paperwork. The chairman of his department set up a meeting to discuss the potential implications of the rules. One of those implications may be increased patient time in other words, more claims for you.

But don't expect the lighter physician documentation load necessarily to translate into more money for your ED. Unless the attending physician spends a lot of time writing notes, the new rules'impact on revenue will be "neutral," Linzer says. In fact, Linzer disagrees with some of the suggested expectations for the rules'relief. "You won't be able to see any more patients in the teaching setting than you currently do," he says, but the rules do make the work "somewhat more hassle-free," he concedes.

More resident charts. Be prepared to deal with residents and their nascent documentation experience and unfamiliar notation. The regulations also give the residents more responsibility in providing well-documented ED charts, Polglase says.
Don't Accept Insufficient Documentation

This "Christmas present," as Lemanski calls it, comes with some warning signs. Heed danger signals and inform your physicians of documentation risks.

Watch out for claims that say too little: Don't liberally assign codes to them. The line between acceptable and unacceptable documentation is "pretty close" when you look at the transmittal, Polglase cautions.

The statement "I was present with the resident during history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note" is now acceptable but could too easily be shortened in a busy ED to "Discussed with resident. Agree," Polglase says. If you see TP documentation that states the latter, don't code for the E/M service under the TP until you see more documentation. The shortened statement "is not considered acceptable by CMS," Polglase states. (See other articles for more on minimal documentation.)

You need to make sure your physicians'documen-tation doesn't reflect inadequacy from a quality-of-care perspective. The teaching physician "must still demonstrate oversight of the resident" and is "still responsible for the resident's actions," Linzer says. You don't want any federal agencies to find neglect in the physician documentation you submit for reimbursement. The physician's "first and foremost obligation is to treat the patient," Polglase says, and that includes ensuring that ED patient a visit by a physician, Lemanski emphasizes.

You might even request that physicians continue to append complete supervisory notes to the claims, Lemanski says. From a quality-of-care and legal perspective, Lemanski "wouldn't be comfortable" coding E/M services with the most minimal documentation from physicians.

"The bottom line is, good documentation equals good patient care," Polglase says. So, you must have a good record of the physician encounter for continuity of care, reimbursement and malpractice considerations, he explains. In addition, physicians owe it to the residents to show them what is considered appropriate documentation, he adds.

When you review the resident's heftier portion of the documentation, make sure the learning is occurring.