ED Coding and Reimbursement Alert

The new teaching physician guidelines mean sparser physician notes. So do stamps now suffice as documentation, in lieu of personally documented attending notes? If you plan to submit TPclaims with stamps to justify your code selection, listen up.

A few experts do plan to use new stamps on the documentation, since physicians no longer need to document key elements of the E/M and need only state their presence and review of resident notes. What you need to know is whether these shortened, uniform ways of meeting the documentation requirements suffice for coding compliance.

Given the new guidelines, Pamela Praast, CPC, at the University Emergency Medicine Foundation in Providence, R.I., asked colleagues about using the following stamps in lieu of attending notes.

1. "I performed an H&Pand discussed the patient's management with the resident. I reviewed the resident's note and agree with the documented findings of _______. I agree with the plan of care ________." Teaching Physician Signature ______________

2. "I saw the patient with the resident and agree with the resident's findings and plans." Signature.

3. "See resident notes for details. I saw and evaluated the patient and agree with the resident's findings and plan." Signature.

Most respondents to her inquiry forecasted that CMS would not look "favorably" upon the stamps, Praast says.

CMS "generally" finds stamps "unacceptable," says Robert Polglase, MD, JD, CEO of Stratagem Group Inc., in Augusta, Ga. In fact, statements in Transmittal 1780 strengthen the argument against stamps. The transmittal states, "Documentation may be dictated and typed, handwritten or computer-generated, and typed or handwritten and must be dated and include a legible signature or identity." There is no mention of stamps.

So Polglase advises that practices not use the stamp and instead develop a template "to be certain" the physician documentation meets minimal requirements.

Praast will use the first stamp as a template, arguing that it can be found in the CMS transmittal. Indeed, CMS states that the sentences in the first stamp listed above satisfy minimal requirements.

Just because your template states what's deemed acceptable by CMS in its transmittal doesn't mean that you won't run into some denials. "You never know how [the rule is] going to be played out," says Mike Lemanski, MD, at Baystate Medical Center, a large teaching hospital with an E/M residency program of 36 residents.

Despite the new regulation's suggestion that TP documentation is obsolete, you should ask your physicians to continue using complete supervisory notes, Lemanski says at least for a while.

The supervising notes Lemanski uses for teaching physicians prompt the key elements of the E/M, including check-off boxes that confirm or disagree with resident and nursing notes. The notes start with the statement that the physician has "reviewed and confirmed" the nursing notes and the Hx, PEx, and treatment by the resident. Then the note touches on the reason for the patient's visit and supplies documentation for the key elements of the history and physical exam. The physician then summarizes the course of treatment of the patient in the ED.

So the guideline's clarifications don't eliminate the need for this kind of documentation; they reiterate that excessive documentation is not necessary. "The question is: How much do TPs have to document, especially on a level-five patient?" Lemanski says, and the clarifications thoroughly answer that question.

With the threat of Medicare allegations citing fraud and abuse, physicians have felt pressure to create "extensive" and often redundant documentation, he states. The new guidelines, a "Godsend," explicitly allow TPs to reference resident's notes, clarify points of discrepancy, and provide additional commentary where needed. "Finally, physicians can document what is clinically appropriate for the patient, reduce the amount of redundancy in our notes, and get on with the business of saving lives," Lemanski says.

But you may want your physicians to provide even more documentation, depending on how worried you are about denials. "I recommend that the TPpersonally document the specific date, findings, problem-specific recommendations to support his presence, and participation," says Marianne Wink, RHIT, compliance analyst and educator at Strong Health Compliance Office in Rochester, N.Y.

Though physicians often use check boxes for "blanket" statements like "I was personally present in rendering service ...," she "strongly" recommends that physicians supply additional personal documentation. Checkboxes alone are "inadequate for quality and reimbursement purposes," she says.

Your local carriers may accept shortened statements, but act on the side of caution until you know how the carriers will respond to the new transmittal. Perhaps your carrier will allow you to use the stamp that Praast will use. But initially, it may be wiser for medical and legal reasons to ask physicians to stick to complete supervisory notes, Lemanski suggests. Wink concurs: Physicians who perform key elements should still document them.

"But these new regulations have the potential to make documentation a whole lot simpler for TPs," Lemanski adds, so we'll have to wait to see how carriers enforce the rules.