Published in the March 2015 issue of Today’s Hospitalist
ARE YOU SUPERVISING RESIDENTS? If you are, documentation is critical for getting paid for the services that residents provide.
But it’s just as important to understand the government’s regulations associated with teaching hospitals, residents and medical students. If you submit claims as a teaching physician, the Centers for Medicare and Medicaid Services (CMS) expects you to know those rules. And government payers continue to scrutinize teaching physicians’ services.
When physicians bill for services provided by residents, their documentation must clearly reflect their active involvement in patient care and management “and the key word is “active.” Teaching physicians cannot be sitting in their recliner at home watching the big game while billing for resident services.
The following information pertains to providing evaluation and management (E/M) services in the hospital, services that include initial hospital care, subsequent hospital visits and emergency department visits. (Note that teaching-physician rules are specific to different types of services. Different rules apply to major surgery, minor procedures, endoscopies, anesthesia, radiology services, and outpatient E/M services.)
According to the CMS, doctors in the hospital can bill for E/M services under teaching-physician rules in the following circumstances:
- The teaching physician personally performs the entire evaluation of the patient without the resident and documents the service as he or she would any E/M service.
- The resident performs the evaluation of the patient with the teaching physician physically present in the room. The physician may or may not perform key portions of the exam.
- The resident performs the evaluation without the teaching physician present. The teaching physician then sees the patient independently without the resident and personally performs key components of the evaluation.
Let’s break those scenarios down into a little more detail and discuss what documentation is required.When teaching physicians are physically present at the bedside with residents for patient evaluations, residents must document all of their own work, just like they would any E/M service. Teaching physicians must also personally document that they were present with a resident during the performance of key or critical elements of the evaluation and were directly involved in patient management.Teaching physicians also need to document that they reviewed the resident’s note and agreed with the resident’s findings. They can then bill the level of E/M service that is based on the cumulative documentation of both the resident and the teaching physician. (Note: When teaching physicians review a resident’s note and don’t agree with what the resident has written, they need to document that lack of agreement as well as their own different findings.)
When physicians and residents evaluate a patient independently, residents must document the evaluation that they performed. Teaching physicians must also personally document the key or critical elements of the evaluation they performed. As in the above scenario, teaching physicians should reference a resident’s note and document that they actively participated in patient management.
Then there’s this situation: either the resident or teaching physician or both use a scribe. Scribes’ notes should specifically indicate when they are scribing for the teaching physician and when they are scribing for the resident; in all their notes, scribes must document the specific name of each physician they are scribing for. They cannot, for instance, document that they are scribing “for the resident.”
Just as importantly, all physicians “both teaching doctors and residents “must document that they have read the scribe’s note and agree with the documentation. Teaching physicians’ signature on a scribed note is their attestation that the note is an accurate record of both their words and actions during the encounter.
How to document
Here are some tips for documenting visits between teaching physicians and residents:
- Note that you reviewed the resident’s note and you agree with his or her findings.
- Document that you personally performed and documented the key or critical components of the evaluation.
- Document that you discussed the management of the patient with the resident.Here are examples of attestations, notes to include in your documentation that each relate to different resident scenarios:
- “I personally performed the physical examination of the patient. I reviewed the resident’s note and agree with the documented findings and plan of care. The resident and I discussed the management of the patient.”
- “I was present with the resident during the key components of the examination. I reviewed the resident’s note and agree with all of the findings, and we discussed the management of the patient together.”
- “I saw and evaluated the patient, reviewed the resident’s note, and agree with her findings and plan of care.”Documentation “don’ts”
Then there are documentation pitfalls to steer clear of:
- Don’t use abbreviated documentation that lacks detail or substance.
- Avoid documentation that does not clearly indicate that you were physically present for and/or personally performed critical or key components of the evaluation.
- Don’t ask the resident to document on your behalf. Here are phrases that aren’t comprehensive enough, so avoid them too:
- “Agree with resident”
- “Discussed with resident and agree”
- “Seen and agree”
- “Patient examined”
Also keep in mind: When a resident provides services, any claims submitted must also have the GC modifier appended to the corresponding CPT codes. That modifier indicates that a resident provided the service and that the documentation for the visit meets all the requirements set forth by teaching-physician rules.
For more detailed information, see the “Medicare Claims Processing Manual,” chapter 12, section 100.
Sue A. Lewis, RN, CPC, PCS, is a coding manager for a nonproﬁt health plan in the Midwest. Send any billing and coding questions you have to her at firstname.lastname@example.org and we may answer them in a future issue.
Medical students and documentation
ANY TIME A MEDICAL STUDENT participates in an encounter or service being billed by a teaching physician, that participation must be performed in the physical presence of a teaching physician or a resident.
In addition, the only portion of a medical student’s documentation that can be used for billing purposes is the review of systems (ROS) and past medical, family and social history (PFSH). Teaching physicians may not refer to a student’s documentation of the history of present illness (HPI), physical examination or medical decision-making. If a medical student performs any portion of an evaluation and management service (other than the ROS and PFSH), teaching physicians must verify and personally re-document the HPI. They must also personally perform and re-document the physical examination and the medical decision-making.