ED Coding and Reimbursement Alert

Reader Question:

Documentation Scenarios from Transmittal 1780

Published on Sat Feb 01, 2003

Below are the three scenarios that CMS offers for teacher physician guidelines verbatim, as referenced in the article on page 4.

#1: The teaching physician personally performs all the required elements of an E/M service without a resident. In this scenario, the resident may or may not have performed the E/M service.

In the absence of a note by a resident, the teaching physician must document as he or she would document an E/M service in a non-teaching setting.
Where a resident has written notes, the teaching physician's note may reference the resident's note. The teaching physician must document that he or she performed the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient. For payment, the composite of the teaching physician's entry and the resident's entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician.
Examples of minimally acceptable documentation for this scenario:

Admitting Note: "I performed a history and physical examination 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."
Follow-Up Visit: "Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note."

Follow-Up Visit: "Hospital Day #5. I saw and examined the patient. I agree with the resident's note except the heart murmur is louder, so I will obtain an echo to evaluate."
NOTE: In this scenario if there are no resident notes, the teaching physician must document as he or she would document an E/M service in a non-teaching setting.

#2: The resident performs the elements required for an E/M service in the presence of, or jointly with, the teaching physician, and the resident documents the service. In this case, the teaching physician must document that he or she was present during the performance of the critical or key portion(s) of the service that he or she was directly involved in the management of the patient. The teaching physician's note should reference the resident's note. For payment, the composite of the teaching physician's entry and the resident's entry together must support the medical necessity and the level of the service billed by the teaching physician.

Examples of minimally acceptable documentation for this scenario:

Initial or Follow-Up Visit: "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."

Follow-Up Visit: "I saw the patient with the resident and agree with the resident's findings and plan."

#3: The resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his or her service. The teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident. In this instance, the teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The teaching physician's notes should reference the resident's note. For payment, the composite of the teaching physician's entry and the resident's entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician.
Examples of minimally acceptable documentation for this scenario:

Initial visit: "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."

Initial or Follow-Up Visit: "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note."

Follow-Up Visit: "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plans as written."

Follow-Up Visit: "I saw and evaluated the patient. Agree with resident's note but lower extremities are weaker, now 3/5; MRI or L/S spine today."