ED Coding and Reimbursement Alert

Question: If no linking statement by the attending is present, which part of the resident's note may be used in levelling an E/M service for a Medicare patient? We use a templated statement after a consultation with our residents and attending physicians, but because of internal issues, their actual documentation does not appear on the chart until well after the ED encounter. Arewe okay?

West Virginia Subscriber

Answer: There has to be a linking statement along the lines of those pasted below from CMS Transmittal 811. Additionally, though the ROS and Past/Family/Social History may be gathered by anyone they must be reviewed and confirmed by the physician. If there is not actual resident documentation, the linking statement would be meaningless.

Following are examples of minimally acceptable documentation from CMS:

• "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." 
• "I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note." 
• "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." 
• "I was present with the 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." 
• "I saw the patient with the resident and agree with the resident's findings and plan." 
• "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." 
• "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note." 
• "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plans as written." 
• "I saw and evaluated the patient. Agree with resident's note but lower extremities are weaker, now 3/5; MRI of L/S Spine today."