CMS documentation guidelines for teaching physicians

Residency Program Insider, April 23, 2007

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Understanding the correct way to document teaching physician participation during a patient visit with a resident is key to billing and coding compliance. While the policies may be tricky to sort out, properly documenting these interactions will help ensure your residents and faculty avoid causing coding errors and billing mistakes.

Educating residents and teaching physicians about these policies not only helps safeguard your institution, but also serves as an excellent teaching opportunity of systems-based practice, one of ACGME's six core competencies.

Whether GME personnel personally direct residents on how to provide patient care, or if the residents assume a greater degree of responsibility, the teaching physician must document the following items to receive payment for teaching physician services:

  • That he or she performed the service or was present during the key or critical portions of the service when performed by the resident
  • His or her personal participation in the management of the patient

Teaching physicians should understand that these billing and compliance issues directly influence their reimbursement. According to the teaching physician documentation guidelines on the Centers for Medicare and Medicaid Services (CMS) Web site, combined medical record entries by the teaching physician and resident constitute the required documentation for correct coding and billing. Together, these entries must support the Evaluation and Management (E/M) services level of care and the medical necessity of the service billed.

The teaching physician documentation may be brief summary comments that relate to the resident's entry, and which confirm or revise the following key elements:

  • Relevant history of present illness and prior diagnostic tests
  • Major finding(s) of the physical examination
  • Assessment, clinical impression, or diagnosis
  • Plan of care

Prior to November 22, 2002, teaching physicians were required to document relevant information on each critical or key element of each billable service, even if the resident already documented the same information accurately. When CMS published the changes to the Medicare Carrier's Manual, Section 15016, it reduced the amount of personal documentation required of the physician when a resident also writes a note. Currently, all required documentation can be provided using a combination of teaching physician and resident documentation, without the teaching physician having to repeat information.

Documentation may be dictated, handwritten, or computer-generated, and must be dated and include a legible signature. In addition, the documentation must identify, at a minimum:

  • The service furnished
  • The participation of the teaching physician in providing the service
  • Whether the teaching physician was physically present

Unacceptable documentation examples, according to CMS, include:

  1. "Agree with above" followed by a legible countersignature or identity

  2. "Rounded, Reviewed, Agree" followed by a legible countersignature or identity

  3. "Discussed with resident. Agree" followed by a legible countersignature or identity

  4. "Seen and agree" followed by a legible countersignature or identity

  5. "Patient seen and evaluated" followed by a legible countersignature or identity

  6. A legible countersignature or identity alone

The teaching physician should not overwrite the resident's consultation report, narrative, or template note, or write in the columns or margins above, below, or beside the resident's documentation. Instead, the teaching physician should document a separately dated and signed narrative progress note or consultation form, placed in chronological chart order, linking to the resident's documentation. When templates are used, especially in certain specialties, they should be designed to support separate resident and teaching physician documentation and allow for each to be individually dated and signed. When more than one resident documents in the chart on the same day, the teaching physician should identify the resident to whom he or she is linking by name or specialty.

Editor's Note: To read more about CMS guidelines and this topic, see the May issue of Residency Program Alert.  

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