Wiki Gyn Exam by a Resident

[Frances A Saad]

In a teaching physician environment. The resident does the E & M, the gyn exam and pap smear. Does the supervising staff have to be present for the GYN Exam or just for the key portions of the visit as they see fit?
Thanks for your input and any supporting documentation would be helpful.

 

[FTessaBartels]

Depends on the payor

Medicare requires that the teaching physician be physically present for the entirety.

Medicaid (in my state) allows the "presence" to be in the immediate vicinity, as long as the teaching physician documents his/her participation and presence for the key portions of the exam.

Commercial payors usually just require "supervision" - that might be by telephone. As long as the resident documents by whom s/he was supervised, we code it.

F Tessa Bartels, CPC, CPC-E/M