Part B Insider (Multispecialty) Coding Alert

Published on Mon Feb 23, 2004 PDF

Documentation requirements changed, but performance requirements still strict

It's been more than a year since the Centers for Medicare & Medicaid Services loosened the reins on teaching physician documentation (in Transmittal 1780, November 2002). But while teaching physicians have gotten more laid-back about their documentation, coders and auditors still worry they're not documenting enough.

"Some of the compliance people are worried they're going to get trapped," says Jeff Linzer, an assistant professor with the division of emergency medicine at Emory University School of Medicine in Atlanta. "They're wanting the teaching physician to write more than what's required by Medicare for billing purposes."

But coders retort that some physicians have become too sloppy in adding to residents' documentation. They've come dangerously close to the sort of "rubber-stamp" phrases CMS says aren't OK in its instructions, such as "Agree with above" or "Seen and agree." Such "incredible shrinking documentation" has some coders worried.

"You no longer have to write the key portions of the history and physical," says Linzer. "The combination of  the teaching physician's and resident's notes determines the level of service."

It's important to be aware that the actual performance requirement for teaching physicians remains strict, says Bart Hershfield, president of CHECKCHART Template Documentation System in Wheeling, W.V., and associate director of the emergency department at Wheeling Hospital. Teaching physicians "have to personally see the patient, and they have to be involved in the key portion of the E/M services ," he says.

And their documentation must show that they personally saw and examined the patient and reviewed the resident's documentation, Hershfield adds. "Certainly the documentation's a lot less than it was." But the teaching physician may also want to write down more details than Medicare requires for billing, for medical-liability reasons.

For coders who remain concerned about the details of documenting inpatient or office E/M services in a teaching physician setting, Part B carrier HGSAdministrators has updated its guidelines: