Oncology & Hematology Coding Alert

Use these tips for surefire documentation Now that you know when you can report an E/M service under the teaching physician rules, you should know what to look for when the oncologist submits the documentation.
 
To satisfy documentation requirements, your oncologist should either write a separate medical note, as in a non-teaching setting, or refer to the resident's note from the earlier visit, says Jillian H. Kuruc, MHA, CPC, CCS-P, a clinical technical editor with Ingenix Health Intelligence in Binghamton, N.Y.
 
When the TP refers to the resident's documentation, he or she may write, "I performed a history and physician exam 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," Kuruc says.
 
The medical documentation should include more than a review of the treatment plan and greeting the patient, she says. To ensure that the physician thoroughly documented the visit, remember to avoid submitting reports to payers with the following phrases and documentation:

   Agree with above.
   Rounded, reviewed, agree.
   Discussed with resident. Agree.
   Seen and agree.
   Patient seen and evaluated. Also, your oncologist should always use the personal pronoun 'I,' not the plural 'we,' when writing a medical note for an E/M service, Kuruc says. The TP should prove that he or she directly managed the patient's care and supervised the resident.