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Supervising residents? Here’s what you need to do to get paid

In academic settings, coding and documentation requirements become much more complicated

February 2007
Resident physicians speaking with supervisor

Published in the February 2007 issue of Today’s Hospitalist.

While physicians who work in community hospitals have to master a maze of confusing rules on coding and documentation, those requirements become even more complicated once you start working as a supervising physician.

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That’s because attending physicians have to pay attention to two different sets of documentation: their own, and that of the residents that they’re supervising. According to the Centers for Medicare and Medicaid Services (CMS), supervising physicians have to go far beyond just rubber-stamping residents’ notations if they expect to be paid. Instead, they need to clearly document the active role they play in patient evaluation and treatment.

Here’s a look at the right and wrong ways to document services when working with residents.

Duties, billing and documentation
According to the CMS, supervising physicians are responsible for making sure that patients seen by residents receive the same caliber of care as if they were working by themselves. And to bill for a service as a teaching physician, you must personally perform key portions of the service or observe a resident performing those key components.

When supervising, your specific duties include the following:

  • reviewing the patient’s history and physical examination, as performed by the resident;
  • personally examining the patient within a reasonable period of time after admission, which Medicare guidelines indicate is within 24 hours;
  • confirming or revising the resident’s diagnosis;
  • determining the patient’s course of treatment;
  • frequently reviewing the patient’s progress; and
  • making sure that interns and residents receive the supervision they need.

As far as billing supervised services, Medicare regulations are fairly straightforward: Physicians need to add a -GC modifier to the CPT code they’re billing for. That modifier certifies that a teaching physician was present during the key portion of the service and was immediately available during the other parts of the service.

(For insurers other than Medicare, physicians should check with local payers to find out their rules for teaching environments.)

But here’s the rub: Even when appending the right modifier, physicians need to appropriately document their supervision so their billing will stand up to scrutiny.

Teaching physicians can document their services either in writing or by dictation. But they must include a personal notation documenting their participation in all three components of an evaluation and management (E/M) service: history, exam and medical decision-making.

Those comments-which are often referred to as “attestations”-may be brief summaries of the resident’s entry, confirming or revising information that residents have already supplied. But attestations should also include any elaboration or correction that is needed as far as the relevant history of present illness, the list of prior diagnostic tests, the major findings of the physical exam, and the diagnosis and plan of care.

In addition, supervising physicians must make sure their documentation includes a legible signature and date.

Common pitfalls
Several reviews done by the CMS have uncovered common documentation errors being made in teaching hospitals. Those include:

  • medical records that lack any entries from the teaching physician;
  • documentation performed by residents of the supervising physician’s involvement;
  • documentation of E/M services done solely by residents, with no supporting or confirmatory information from the teaching physician; and
  • insufficient documentation from the teaching physician that consists of only a co-signature. As CMS guidelines make clear, a co-signature does not sufficiently document a supervising physician’s presence or extent of involvement.

Here’s an even more common error: brief attestations-such as “reviewed and agree”-from teaching physicians that are too scant to establish the physician’s presence, evaluation or engagement.

Supervising physicians need to craft attestations that clearly delineate their involvement in the service being billed and underscore their supervisory role. (See “Documentation for supervising physicians: Brevity can hurt,” below.)

Time-based criteria
Another coding problem that frequently comes up for hospitalists who supervise residents is how to properly account for time when providing services that have time-based criteria. Some of the E/M codes that are based on time include critical care, hospital discharge and prolonged services, as well as services in which counseling and/or coordination of care account for more than 50% of the physician time spent.

The CMS is very clear on this point: Teaching physicians must be present for the entire period of time reflected in the code chosen. If teaching physicians choose a critical care code based on providing 30 minutes of service, for instance, they must be present for that entire stretch of time.

They may not add time spent only by a resident to their own time to come up with a 30-minute total. Instead, they would need to choose another E/M code to bill, even if that code is not time-based.

Tamra McLain is an independent coding consultant in Southern California. E-mail your documentation and coding questions to her or send a fax to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.


Documentation for supervising physicians: Brevity can hurt

When working with residents, teaching physicians must provide enough documentation to establish their presence and involvement in patient evaluation and treatment. Here are examples of notations that the Centers for Medicare and Medicaid Services will-and will not-accept as sufficient documentation from supervising physicians:

Documentation do’s …

  • “I performed a history and physical exam 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.”
  • “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.”
  • “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia.”
  • “See resident’s note for details. I saw and evaluated the patient and
  • agree with the resident’s finding and plans as written.”

… and don’t’s

  • “Agree with above.”
  • “Rounded, reviewed, agree.”
  • “Discussed with resident. Agree.”
  • “Seen and agree.”
  • “Patient seen and evaluated.”