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Teaching Physician Documentation

  1. #1
    Default Teaching Physician Documentation
    Exam Training Packages
    Is it considered enough documentation to link the residents note when the teaching physician dictates the following statement?

    "pt. seen and examined. Agree with above. Proceed with chemotherapy. Signature ." or "Agree with above plan. Pt has diarrhea, not eating. signature ."

    It's my thoughts that more is need to id the link to resident's note.

    Thanks in advance for your comments.

    Glynis

  2. #2
    Default
    That is how our physician's dictate and our medicare rep gave the okay... i would say yes it's enough... anyone disagree ??

  3. Default Teaching Physician Rules
    I have attached the following website that has an 11 page document that reviews all of the teaching physician documentation guidelines for each coding area... E&M, surgery, anesthesia, etc. I work in a large teaching hospital and this is one of the best references that I have ever found! I frequently give copies of the information to our phsicians.

    I have this helps-

    http://www.aamc.org/advocacy/library...phys/mtpdi.pdf

    Kelley Steincamp, CPC, CHC

  4. #4
    Default
    Quote Originally Posted by steincamp View Post
    I have attached the following website that has an 11 page document that reviews all of the teaching physician documentation guidelines for each coding area... E&M, surgery, anesthesia, etc. I work in a large teaching hospital and this is one of the best references that I have ever found! I frequently give copies of the information to our phsicians.

    I have this helps-

    http://www.aamc.org/advocacy/library...phys/mtpdi.pdf

    Kelley Steincamp, CPC, CHC
    Thanks, that was a great article, we usually give our TP this article
    http://www.cms.hhs.gov/MLNProducts/d...gresfctsht.pdf

    But i think your article is easier to understand and gives examples.

  5. #5
    Location
    Jacksonville, FL River City Chapter
    Posts
    74
    Default
    Be aware that the AAMC article is based on outdated TP rules (the 1996 rules), which required the TP to participate in the portions of the service "that determine the level of service billed." Since everyone assumed that "key portions" meant "key components," most instructed that these rules meant that the TP must be participate in and leave a summary comment for hx/exam/mdm for those visits billed based on 3 key components and 2 of those 3 for visits based on 2/3.

    This requirement and verbiage was removed from Medicare's TP Guidelines as of November 2002. Medicare as of that time no longer required the provider to leave summary comments in their TP notes for certain key components.

    I'm amazed at how many resources are out there that have never been updated to reflect this.

    Seth Canterbury

  6. #6
    Default
    My compliance person said this wouldn't pass when I ask her. I have my attending to go in and exam the patient and document their finding and agree or disagree with the resident. Hope this will help.

  7. #7
    Default
    Quote Originally Posted by steincamp View Post
    I have attached the following website that has an 11 page document that reviews all of the teaching physician documentation guidelines for each coding area... E&M, surgery, anesthesia, etc. I work in a large teaching hospital and this is one of the best references that I have ever found! I frequently give copies of the information to our phsicians.

    I have this helps-

    http://www.aamc.org/advocacy/library...phys/mtpdi.pdf

    Kelley Steincamp, CPC, CHC
    The link to Association of American Medical Colleges was just what I needed today. Thank you!
    DJ

  8. #8
    Location
    Longmont Colorado
    Posts
    20
    Default tie-in statement
    I will tell you that every example that you can find of an adequate tie-in statement will include a personal pronoun. It is necessary to establish the physical presence of the attending physician, and if you cheat with "patient seen and examined" someone will ask "who saw and examined them?"
    I give the following example to my teaching physicians, and hope they come close: "I have seen and examined the patient, I agree with the assessment and plan as outlined by Dr. X."
    If they show both their physical presence and their participation with the resident it should stand up to audit.
    Brad Howard, CPC, AHIMA Approved ICD-10 CM/PCS Trainer
    McKesson Specialty Health
    brad.howard@mckesson.com

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