Neurology & Pain Management Coding Alert

Under new Medicare rules, teaching physicians will find it easier to document services provided with residents and medical students. CMS will no longer require physicians to repeat services already provided by residents and instead will focus on the key elements of care. No More History Repeating Prior to the new guidelines (effective Nov. 22, 2002), Medicare required attending physicians to document the key elements of history, exam and medical decision-making (MDM) separately, in addition to noting their personal presence (or independent verification) and discussion of a resident's findings. The implication was that the teaching physician performed the complete service but did not duplicate the resident's note.

"The rules were created to prevent physicians from being paid twice for supervision of residents," says William Rogers, MD, chair of CMS' Physician Regulatory Issues Team that guided the discussion of the new rules. Medicare Part A pays for resident supervision while Part B reimburses for treatment of beneficiaries. In the past, Rogers says, physicians could sign off on a resident physician's care without ever seeing the patient. This is a problem if the teaching physician then bills Medicare Part B, a practice that led to the Physician at Teaching Hospital (PATH) audits of the last decade and settlements reaching as much as $30 million.

The new rules are more in line with academic practice of medicine, in which a resident presents the case to an attending physician, who then confirms the key elements without repeating the entire history and exam. The essential element that teaching physicians must document under the new guidelines is their personal involvement in the key, critical portions of evaluating and managing a patient. The physician may then bill a level of service that reflects the combined cognitive work of both attending the patient and supervising the resident.

Medicare announced the new guidelines in CMS Transmittal 1780, which significantly changed section 15016 of the Medicare Carriers Manual. The transmittal states that faculty physicians must personally document at least that they tended to the patient personally or were physically present during the key or critical portions of the service when performed by the resident and that they participated in the patient's management. Relieving teaching physicians of the requirement that they separately document the "key portions" of the history, exam and MDM reflects CMS' awareness that an attending physician's service to a patient includes both direct care and overall management of a healthcare team of residents, medical students, and ancillary staff. Now teaching physicians must document only that they "personally saw the patient, personally performed the critical or key portions of the service, and participated in the management of the patient," according to the CMS transmittal. Watch Your Words Examples of acceptable documentation [...]