REVISED
TEACHING PHYSICIAN DOCUMENTATION REQUIREMENTS
CMS
revised the teaching physician (TP) guidelines and rules November 22, 2002.
These revised guidelines and rules reduced
the amount of E & M documentation by the TP when a resident is involved in providing the
service (jointly). However, the new guidelines and rules
still require that the TP personally perform critical
or key portions of the E & M service in order to
bill.
The
Teaching Physicians do not have to repeat the
documentation of the resident when they see
the patient.
Listed
below is the minimum documentation required by the TP
when the services to a patient involves a resident:
1.
The TP must document that he/she personally saw the
patient.
2. The TP must document that he/she participated in
the management of the patient, and
3. The TP must document that he/she reviewed the resident’s
note and/or discussed the case with the resident.
Example
#1: “I saw and evaluated the patient.
Discussed with resident and agree with Dr. X’s
(the resident) findings and plan as documented in Dr.
X’s note.”
Example
#2: “I saw and evaluated the patient. I reviewed the
resident’s note and agree except that………
The
following are examples of unacceptable documentation.
“Agree
with above”
“Rounded, review, agreed.”
“Discussed with resident. Agree.”
“Seen and agree”
“Patient seen and evaluated”
Signature alone
·
Note: No changes were made to documentation requirements
for any other services, including the Primary Care Exception
rule.
If
you have any questions, you may contact
Ms.
Sarita Cathcart at 404-756-1353 or by
e-mail – scathcart@msm.edu
Rosie Callender rcallender@msm.edu
For
Medicare’s Carrier Manual Memorandum released
11/22/2002
click Teaching Documentation Guidelines - Medicare
or for a local copy please click here
Local Copy - Teaching Documentation Guidelines - Medicare
For revised and New VA requirements
for Resident Supervision, please go to "In the Spotlight" Resident
Supervision Handbook -
click- http://www.va.gov/oaa/
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