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ED Coding and Reimbursement Alert

You Be the Coder:

What are the rules for physical presence in a teaching setting?

Published on Mon Nov 21, 2011

Question: We are getting a lot of feedback that our emergency physician faculty members, who are supervising residents, can't report procedures that allow "supervision of key components." Rather, we are told that they must remain at the bedside the entire time in order to bill for the procedure. For many procedures, this isn't a problem, but watching a 1st year resident sew up a 15cm laceration for an hour isn't practical in a busy ED. Of course, the physicians are always within the department, but do they have to remain at the bedside for the entire procedure? Our charting system offers two check boxes: 1. "I was present for and supervised the entire procedure" and 2. "I was present for key components of the procedure." For number 2, we aren't billing. While we are on that topic, what exactly is "present"? Does it mean in the same room, in the [...]
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