100.1.1 - Evaluation and Management (E/M) Services
(Rev. 2303, Issued: 09-14-11, Effective: 06-01-11, Implementation: 07-26-11)
A. General Documentation Instructions and Common Scenarios
Evaluation and Management (E/M) Services -- For a given encounter, the selection of the
appropriate level of E/M service should be determined according to the code definitions
in the American Medical Association's Current Procedural Terminology (CPT) and any
applicable documentation guidelines.
For purposes of payment, E/M services billed by teaching physicians require that they
personally document at least the following:
• That they performed the service or were physically present during the key or
critical portions of the service when performed by the resident; and
• The participation of the teaching physician in the management of the patient.
When assigning codes to services billed by teaching physicians, reviewers will combine
the documentation of both the resident and the teaching physician.
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.
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.
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Following are examples of minimally acceptable documentation for each of these
scenarios:
Scenario 1:
Admitting Note: “I performed a history and physical examination 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.�
Follow-up Visit: “Hospital Day #3. I saw and evaluated the patient. I agree with the
findings and the plan of care as documented in the resident's note.�
Follow-up Visit: “Hospital Day #5. I saw and examined the patient. I agree with the
resident's note except the heart murmur is louder, so I will obtain an echo to evaluate.�
(NOTE: In this scenario if there are no resident notes, the teaching physician must
document as he/she would document an E/M service in a non-teaching setting.)
Scenario 2:
Initial or Follow-up Visit: “I was present with the resident during the history and exam.
I discussed the case with the resident and agree with the findings and plan as documented
in the resident's note.�
Follow-up Visit: “I saw the patient with the resident and agree with the resident's
findings and plan.�
Scenarios 3 and 4:
Initial Visit: “I saw and evaluated the patient. I reviewed the resident's note and agree,
except that picture is more consistent with pericarditis than myocardial ischemia. Will
begin NSAIDs.�
Initial or Follow-up Visit: “I saw and evaluated the patient. Discussed with resident and
agree with resident's findings and plan as documented in the resident's note.�
Follow-up Visit: “See resident's note for details. I saw and evaluated the patient and
agree with the resident's finding and plans as written.�
Follow-up Visit: “I saw and evaluated the patient. Agree with resident's note but lower
extremities are weaker, now 3/5; MRI of L/S Spine today.�
Following are examples of unacceptable documentation:
“Agree with above.�, followed by legible countersignature or identity;
“Rounded, Reviewed, Agree.�, followed by legible countersignature or identity;
“Discussed with resident. Agree.�, followed by legible countersignature or identity;
“Seen and agree.�, followed by legible countersignature or identity;
“Patient seen and evaluated.�, followed by legible countersignature or identity; and
A legible countersignature or identity alone.
Such documentation is not acceptable, because the documentation does not make it
possible to determine whether the teaching physician was present, evaluated the patient,
and/or had any involvement with the plan of care.
