College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP -
Requirements and time limitations for using
a Resident's Note in support of a billable service

The federal regulations for physician services in teaching settings is described in 42 CFR, section 415, subpart D, and further federal guidance is provided in the Medicare Carrier's Manual §15016.

The rules describe requirements for both documentation and the teaching physician's participation in the service. A teaching physician must meet the physical presence rules for procedures. Procedures provided by residents when the presence/supervision requirements are not met are "Resident Only" and are not billable.

But what about Evaluation and Management services where the resident sees the patient in evening/night/weekend hours and the teaching physician sees the patient the following morning? Can the teaching physician use the resident's note in support of his or her service?

While CMS has not provided specific time frames, the College Compliance Committee guidance is no more than a lapse of 12 hours between the time the Resident sees the patient and the Teaching Physician.

EXAMPLES:

YES : CAN COMBINE WITH RESIDENT'S NOTE: A Resident sees the patient at 11:00 pm on November 6 and the Teaching Physician sees and evaluates the patient and reviews the Resident's note at 7:00 a.m. November 7.

Sample Note: "I saw and evaluated the patient at 6 am on 11/3/08. I have discussed the case with the resident (name of the resident who dictated H&P) and confirmed the findings of the resident's physical examination. I agree with plan as documented in the resident's note."

NO: DO NOT USE THE RESIDENT'S NOTE: A Resident responds to an inpatient consultation request at 3:00 p.m November 6. The Teaching Physician is in clinic. The Resident assesses the patient as stable, and can wait to be seen the following day. The Teaching Physician sees the patient at 3:00 pm on Nov 7.

Requirements to link to Resident's note from previous calendar date:

• No more than a lapse of 12 hours between the time the Resident sees the patient and the Teaching Physician.
• The Teaching Physician must repeat the key elements of the exam, and document all changes in condition of the patient from the time of the Resident's documentation.
• The resident's note can only be linked to one Teaching Physician note.
• The Teaching Physician can only link to a note generated by the same resident with whom he or she has discussed the case.
• Resident's note was generated on a previous calendar date at a time when the Teaching Physician was not providing other patient services (late night, weekends after weekend rounding).
• The date of service is the date the Teaching Physician saw the patient.
• Procedures performed without meeting Teaching Physician supervision are "Resident only" and are not billable

NOTE:

• The guidance above is only for Resident/Teaching Physician notes. Physician/ARNP/PA notes with different calendar dates may not be combined.
• If you are providing services on our Jacksonville campus, please contact the Jacksonville Compliance Office regarding their policy.

Return to Q&A page          Compliance main page            College of Medicine home page

---

Webmaster<athagan@ufl.edu>College of Medicine, Office of Compliance    This page created November 10, 2009 Please read our disclaimer and permitted use statement.