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Documentation at a Teaching Institution

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

Documentation at a Teaching Institution
What are the responsibilities of a teaching physician when billing evaluation and management services? There must be a physical presence! Clearly, the teaching physician must see the patient and participate personally in the patient’s care. This can be accomplished by personally performing the key portions of the service or observing the resident performing them. If the resident has seen the patient independently, the teaching physician must repeat the key elements of the examination. As always, documentation is paramount. Examples of appropriate documentation would be: “I was present with the resident during the history and examination”; “I discussed the case with the resident and agree with the findings and plan as documented”; “I saw and evaluation the patient”; “I reviewed the resident’s note and agree, with the exception that I feel the diagnosis is pericarditis rather than myocardial ischemia”; “I saw and evaluated the patient and agree with the resident’s note, but lower extremities are weaker, now 3/5, MRI of the lumbar spine has been ordered for today.”

Examples of inappropriate documentation would be: “I agree with above”; “Rounded, reviewed and agree”; “Discussed with the resident and agree”; “Seen and agree”; “The patient was seen and evaluated”; or merely signing the note. The inappropriate documentation examples are inadequate because they fail to show physical presence and a substantive addition to the management. Also, it is highly important to understand that all comments should be legible, or they may as well not be there.