Wiki teaching physician

[cbunti]

I am coding for a surgeon temporarily while some of the staff is out. This is not my field of expertise and would like to hear your thoughts. She is a teaching physician and sometimes the surgeon will document in her notes "patient seen and examined." She will generally follow that with her recommended treatment. (The student will also dictate the entire consult at times). Does this qualify for billing an E&M? My understanding was that she had to redocument the exam (not just a statement "examined") and decision making.

 

[j.berkshire]

I am coding for a surgeon temporarily while some of the staff is out. This is not my field of expertise and would like to hear your thoughts. She is a teaching physician and sometimes the surgeon will document in her notes "patient seen and examined." She will generally follow that with her recommended treatment. (The student will also dictate the entire consult at times). Does this qualify for billing an E&M? My understanding was that she had to redocument the exam (not just a statement "examined") and decision making.

If the documentation is by a student, nothing but ROS and/or PFSHx can be counted. If the documentation is by a resident/fellow, the documentation can combine with the teaching physician's for billing purposes. The teaching physician must document s/he "saw and examined" and link his/her note to the resident/fellow. Linking can be documented by verbiage examples of "see resident's note," or "agree with resident."