Special Documentation Required When Physicians Supervise Residents in Teaching Setting
Published on Wed Dec 01, 1999
In teaching hospitals (hospitals with graduate medical residency programs), emergency department (ED) physicians often supervise medical residents, providing guidance adnd oversight as the physicians-in-training treat patients.
Because the teaching physician physically may not perform all of the services provided during the patient visit but is legally responsible for the care provided by the residents he or she supervises, the Health Care Financing Administration (HCFA) has special rules governing how teaching physicians and residents report procedures and services.
Physician Must Be Present During
Key Portion of Service
HCFAs carrier instructions concerning how to reimburse teaching physician and resident medical services state that if a resident participates in a service furnished in a teaching setting, pay for the service of a teaching physician under the physician fee schedule only if the teaching physician is present during the key portion of the service for which payment is sought.
The instructions do not state, however, what a key portion is. It is difficult to understand from a laypersons perspective, it is more of a clinical determination, explains John Donnan, MBA, administrative manager for the emergency department at Massachusetts General Hospital, Boston, MA. For example, in a lumbar puncture, if the resident performs the procedure, the teaching physician must be present to oversee the placement of the needle in the space and to see that spinal fluid and not blood is drawn. And if a long-bone fracture is set, the physician must be there to determine that the bone is set and that the splint or cast does not compromise neuromuscular function. Basically, the physician must be there during the portion of the visit in which the main treatment is performed. The ED physician cannot just stick his or her head in the door and then bill for the visit.
The documentation by the teaching physician and resident must indicate his or her presence during the performance of the procedure.
For evaluation and management (E/M) services, the key portions are: a relevant history of present illness and prior diagnostic tests; the major findings of the physical examination; the assessment, clinical impression or diagnosis; and the plan of care, advises Todd Thomas, CPC, CCS-P, president of Oklahoma City, OK-based Thomas and Associates, a consulting firm specializing in emergency medicine practice management and reimbursement.
If the teaching physician is present during the patient encounter and all of the required elements are obtained and documented by the resident, the resident should include in the documentation the teaching physicians presence and participation in the key components of the visit, says Thomas. The teaching physicians actual documentation may be minimal, but it must include confirmation of the performance of the key components [listed above] and the teaching physicians presence during that [...]
