Wiki Help! Teaching Physician and Resident services

[Love Coding!]

Hello,

Scenario - Teaching facility (i.e hospital), specialty OB

OB/GYN - example

Day 1. Initial H&P
day 2. Antepartum visit
Day 3. Delivery
Day 4. Postpartum visit
Day 5. Postpartum visit
Day 6. Discharge

If the training physician was present throughout these visits with the resident would the "linking" statement by CMS need to be recorded for each of these visits listed above?

"I performed a history and physical on the patient and discussed her management with the resident/midwife above. I reviewed the resident's/midwife note and agree with the documented findings and plan of care."

 

[midnightsun1369]

yes.

the medicare learning network has a guidelines for teaching physicians, interns and residents fact sheet.

below info came from that:
When a teaching physician bills for E/M
services, he or she must personally
document at least the following:
* That he or she performed the service
or was physically present during the
critical or key portions of the service
furnished by the resident; and
* His or her participation in the
management of the patient.
On medical review, the combined entries into
the medical record by the teaching physician
and resident constitute the documentation
for the service and together must support the
medical necessity of the service. Documentation
by the resident of the presence and
participation of the teaching physician is
not sufficient to establish the presence and
participation of the teaching physician.

 

[Love Coding!]

yes.

the medicare learning network has a guidelines for teaching physicians, interns and residents fact sheet.

below info came from that:
When a teaching physician bills for E/M
services, he or she must personally
document at least the following:
* That he or she performed the service
or was physically present during the
critical or key portions of the service
furnished by the resident; and
* His or her participation in the
management of the patient.
On medical review, the combined entries into
the medical record by the teaching physician
and resident constitute the documentation
for the service and together must support the
medical necessity of the service. Documentation
by the resident of the presence and
participation of the teaching physician is
not sufficient to establish the presence and
participation of the teaching physician.

Thank you much appreciated!