Separate resident and attending clinic notes

Bernadette10

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The resident saw a patient in the clinic and wrote his note, which the attending physician cosigned. The attending physician then wrote a separate note with the same date and time which he signed. Can both of these notes be used to determine the level and diagnoses for the visit, or can only the attending's note be used since he didn't include an attestation statement for the resident's note? They obviously both saw the patient, but the notes are slightly different.
 

Pathos

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Medicare Claims Processing Manual Chapter 12 explains:

"100.1.1 - Evaluation and Management (E/M) Services (Rev. 4068, Issued: 05-31-18, Effective: 01-01-18, Implementation: 03-05-18)

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."



Yes, you can use both notes combined if the Teaching Provider produced the Teaching Physician's requirements in the Resident's chart, or in the Teaching Physician's chart as long as the Teaching Physician is referencing the Resident's chart correctly. The fact that the services performed were on the same date, also allows you to use both notes, as long as the previous requirements are met.

Hope that helps!
 

Bernadette10

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Thanks, this helps, but the teaching physician didn't reference the resident's note at all, other than signing it. So this is where I'm confused. Is the TP's signature on the resident's note enough to let me use it and combine it with the TP's separate note? The TP's note is shorter and would give a lower level. The resident's note is more detailed.
 

Pathos

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If documentation does not provide an attestation (see my previous post) and signature from the Teaching Physician, then the resident is billing for themselves (which they usually can't since they're probably not credentialed as a billing provider).

CMS Teaching Physician guidelines explain further:

"GENERAL DOCUMENTATION GUIDELINES
Both you and residents may document physician services in the patient’s medical record. The documentation must be dated and contain a legible signature or identity and may be completed using one of these methods:

  • Dictated and transcribed
  • Typed
  • Hand-written, or
  • Computer-generated
You may use a macro, which is a command in a computer or dictation application in an electronic medical record that automatically generates predetermined text that is not edited by the user, as the required personal documentation if you personally add it in a secured or password-protected system. In addition to your macro, either you or the resident must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. If both you and the resident use only macros, it is not considered sufficient documentation."

In other words, in order to use and combine both charts, then the above requirements must be met (attestation and signature from the Teaching Physician).
 
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