Teaching Physician Note HELP

lmz0330

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I have a question regarding acceptable documentation that physician was present during exam, reviewed Fellow note and agree.

I have a physician who wants to use a check list on the charge slip stating he was present and agrees with Fellow documentation. This is not in the "note", but is in the chart.

Is this allowed? Also, He uses one billing sheet for multiple visits so this is only stated one time.

I thought each note needs to specifically state what portion of exam was done by physician and that he agrees or disagrees with notes documented by fellow.

Please Help, getting a really bad feeling on this
 

kjludwig

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You can find information regarding acceptable documentation in a teaching setting/scenerio on the Medicare website. Such as Medicare Claims Processing Manual Chptr 12 Section 100-Teaching Physician. Also there is a reference in the MLN "Guidelines for Teaching Physician, Interns & Residents. On the Medicare Website if you just type "Teaching Physician" in the search box you will see a lot of related articles. You are right to be concerned!!!!! This is an area looked at by the OIG(Office of Inspector General). Huge fines and penalties have been levied in this situation due to the lack of proper documentation clarifying the role of the teaching physician. I can locate articles for you to show your physician regarding this fines and penalties if you need them to review with your physician to make him aware of the importance of proper documentation. Hope this helps
 
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