documentation requirements are for attendings when they supervise residents

[kviolet]

I was hoping that somebody would provide me with some clarification about what the documentation requirements are for attendings when they supervise residents- in terms of being able to bill optimally for a visit.

The requirements vary based on Level of Care?
If so, please outline what exactly elements are needed in the attending note specifically in order to bill the following levels. Also- please specify what elements need to be included in the resident note in order minimize what the attending needs to document in their note.

SO- for example- for a Level 4 visit if the resident writes a complete H&P, completes a full review of systems and physical exam which includes every organ system; and completes family history, past medical history and social history. If the resident also documents their assessment and plan, what specifically needs to be included on the note written by the attending in order to bill.

Level 3
Level 4
Level 5
Thank you !

 

[sswisher]

"On medical review, the combined entries into the medical record by the teaching physician and the resident constitute the documentation for the service and together must support the medical necessity of the service."

http://www.acep.org/Clinical---Practice-Management/Teaching-Physician-Guidelines-FAQ/