Pulmonology Coding Alert

Question: My physicians work at a teaching hospital. What should I look for in the documentation to make sure the teaching physician has satisfied the Medicare supervision requirements?


New York Subscriber


Answer: Medicare requires that your teaching physician (TP) either see the patient solely or, if in conjunction with the resident, perform the key/critical aspects of the patient's evaluation and participate in the management of the patient.

When your TP refers to the resident's documentation, he may write, "I performed a history and physical 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."

Pointer: Your pulmonologist should include more than a review of the treatment plan and greeting the patient in his medical documentation. Instruct your physicians to steer clear of the following phrases in their documentation, because they are examples of inadequate tethering statements:

• Agree with above.
• Rounded, reviewed, agree.
• Discussed with resident. Agree.
• Seen and agree. Phrases such as these don't provide enough information to the insurance carrier. You should also advise your pulmonologists to use the first-person pronoun in their documentation, which helps prove that they directly managed the patient's care and supervised the resident's work. For example, "I checked the chest tube for the presence of an air leak" indicates who did the work, whereas payers could interpret "Check chest tube for an air leak" as orders to a resident.