Documentation includes information about the teaching physician’s presence during the encounter, performance of the critical or key portions of the service and involvement in patient management, as well as a reference to the resident’s note. As in scenario one, the teaching physician selects the visit level based on the combined documentation.
Teaching physician statements associated with scenario two and accepted by Medicare reviewers include the following:
- “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 the patient with the resident and agree with the resident’s findings and plan.”
Scenario two examples contain generalized statements considered acceptable for billing under teaching physician rules. Documenting patient-specific elements of the assessment and plan, however, not only demonstrate teaching physician involvement in patient care, but also evidence better quality of care.
Scenario Three: The Shared Service. In this case, the resident performs a portion or all of the required service elements without the teaching physician present and then documents the services. The teaching physician independently performs only the critical, or key, portions of the service and, as appropriate, discusses the case with the resident. Similar to scenario two, the TP references the resident’s note and documents presence during the encounter, performance of the critical or key portions of the service and involvement in patient management.
Remember, the teaching physician can not link to a resident note that does not exist. In other words, if the resident’s note is not available when the teaching physician is documenting, the note cannot be considered for billing purposes. When documented appropriately, as in the scenarios above, the teaching physician selects the visit level based on the combined documentation.
Medicare-approved linkage statements for use by teaching physicians in this scenario include the following:
- “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. Will begin NSAIDs.”
- “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
- “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
- “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S spine today.”
Documentation of teaching physician presence and participation provided solely by the resident is not sufficient to support the teaching physician service. Some examples of unacceptable documentation include:
- “Agree with above,” followed by legible countersignature or identity;
- “Rounded, Reviewed, Agree,” followed by legible countersignature or identity;
- “Discussed with resident. Agree,” followed by legible countersignature or identity;
- “Seen and agree,” followed by legible countersignature or identity;
- “Patient seen and evaluated,” followed by legible countersignature or identity; and
- Legible countersignature or identity alone.
Time-Based Services
Time-based E/M services require the teaching physician be present for the entire period for which the claim is made. Medical record documentation should reflect the teaching physician’s total visit time (i.e., spent on the unit/floor for inpatient services), including face-to-face time with the patient.
Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s time, nor does time the TP spends teaching activities unrelated to patient care. Examples of time-based services typically provided by hospitalists include: