College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP

Download complete text of the CMS
Part 3 - Claims Process
Transmittal 1780
Adobe reader required 

Effective November 22, 2002, via Transmittal Document 1780,
CMS has revised the documentation requirements for
Supervising Physicians in Teaching Settings

**Note: These rules do not apply to or change in any way the existing presence and
documentation rules pertaining to services involving non-physician practitioners.**

This tip is divided into four sections:

I.    Requirements for Teaching Physician presence/participation and documentation of Evaluation and Management services (including specific examples for acceptable and unacceptable documentation by Teaching Physicians);

II.    Prohibition on use of Medical Student Performance and Documentation of E&M services, except for ROS and PSFH;

III.    Requirements for Teaching Physician presence, performance, and documentation of Procedures;

IV.    Applicable Definitions.

1.    Presence/Participation: A teaching physician (TP) may bill and be reimbursed for services involving residents that either (1) the TP personally furnishes or (2) the TP was physically present during the critical or key portions of the services that a resident performs.

2.    Documentation:

For purposes of payment, E/M services billed by teaching physicians require that they personally document at least the following:

That they performed the service or were physically present during the key or critical portions of the service when performed by the resident; and

The participation of the teaching physician in the management of the patient. When assigning codes to services billed by teaching physicians, reviewers will combine the documentation of both the resident and the teaching physician.

Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician. On medical review, the combined entries into the medical record by the teaching physician and the resident constitute the documentation for the service and together must support the medical necessity of the service.

NOTE: What the resident did and documented may be combined with what the Teaching Physician did and documented to support a service.   The Teaching Physician must only perform the key elements of the exam.

The resident's note must be available to review.  For example, if the resident's note supports a 99203 and the Teaching Physician is billing a 99205, then the Teaching Physician's note must include additional documentation required to support the service.    This rule change now makes it permissible to append the Teaching Physician documentation when reviewing the Resident's note, upon condition that the time lapse between the date of service, and appending the note is reasonable.

CMS HAS STATED NO STAMPS  OR DICTATION MACROS ARE PERMITTED.  CMS stated that they have stripped the required language to a minimum, and require the Teaching Physician to make the statement PERSONALLY.

These rules are not retroactive,
and cannot be applied to documentation prior to November 22, 2002.

Following are examples of minimally acceptable documentation for
each of three scenarios for E&M encounters in teaching settings:

Scenario 1

The teaching physician personally performs all the required elements of an E/M service without a resident. In this scenario the resident may or may not have performed the E/M service independently

Admitting Note: "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care."

Follow-up Visit: "Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note."

Follow-up Visit: "Hospital Day #5. I saw and examined the patient. I agree with the resident's note except the heart murmur is louder, so I will obtain an echo to evaluate."

(NOTE: In this scenario if there are no resident notes, the teaching physician must document as he/she would document an E/M service in a non-teaching setting.)

Scenario 2

The resident performs the elements required for an E/M service in the presence of, or jointly with, the teaching physician and the resident documents the service. In this case, the teaching physician must document that he or she was present during the performance of the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient. The teaching physician's note should reference the resident's note. For payment, the composite of the teaching physician's entry and the resident's entry together must support the medical necessity and the level of the service billed by the teaching physician)

Initial or Follow-up Visit:     "I was present with 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."

Follow-up Visit:     "I saw the patient with the resident and agree with the resident's findings and plan."

Scenario 3

The resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his/her service. The teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident. In this instance, the teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The teaching physician's note should reference the resident's note. For payment, the composite of the teaching physician's entry and the resident's entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician.)

Initial Visit:     "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs."

Initial or Follow-up Visit:     "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note."

Follow-up Visit:     "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plans as written."

Follow-up Visit:     "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."

Following are examples of unacceptable documentation:

"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

A legible countersignature or identity alone.

Such documentation is not acceptable, because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.

II.    PROHIBITION ON USE OF MEDICAL STUDENT PERFORMANCE AND DOCUMENTATION OF E&M SERVICES, EXCEPT FOR ROS AND PSFH;

Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record.   However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student's documentation of physical exam findings or medical decision making in his or her personal note. If the medical student documents E/M services, the teaching physician must verify and re-document the history of present illness as well as perform and re-document the physical exam and medical decision making activities of the service.

NOTE:    The only Medical Student documentation that supports a portion of the bill is the Review of Systems and the Past, Family/Social History portion of the history.  The teaching physician must both perform and document the rest of the service.   The teaching physician must repeat the exam, even if the medical student performed the exam in the teaching physician's presence - except for those elements that the Teaching Physician can assess by observing the medical student's performance of the element (for example: gait).

III.    PROCEDURES

In order to bill for surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.

Surgery (Including Endoscopic Operations).--The teaching surgeon is responsible for the preoperative, operative, and post-operative care of the beneficiary. The teaching physician's presence is not required during the opening and closing of the surgical field unless these activities are considered to be critical or key portions of the procedure. The teaching surgeon determines which post-operative visits are considered key or critical and require his or her presence. If the post-operative period extends beyond the patient's discharge and the teaching surgeon is not providing the patient's follow-up care, then instructions on billing for less than the global package in §4824.B apply. During non-critical or non-key portions of the surgery, if the teaching surgeon is not physically present, he or she must be immediately available to return to the procedure, i.e., he or she cannot be performing another procedure.  If circumstances prevent a teaching physician from being immediately available, then he/she must arrange for another qualified surgeon to be immediately available to assist with the procedure, if needed.

Single Surgery.--When the teaching surgeon is present for the entire surgery, his or her presence may be demonstrated by notes in the medical records made by the physician, resident, or operating room nurse. For purposes of this teaching physician policy, there is no required information that the teaching surgeon must enter into the medical records.

Two Overlapping Surgeries.--In order to bill Medicare for two overlapping surgeries, the teaching surgeon must be present during the critical or key portions of both operations.  Therefore, the critical or key portions may not take place at the same time. When all of the key portions of the initial procedure have been completed, the teaching surgeon may begin to become involved in a second procedure. The teaching surgeon must personally document in the medical record that he/she was physically present during the critical or key portion(s) of both procedures  When a teaching physician is not present during non-critical or non-key portions of the procedure and is participating in another surgical procedure, he or she must arrange for another qualified surgeon to immediately assist the resident in the other case should the need arise. In the case of three concurrent surgical procedures, the role of the teaching surgeon (but not anesthesiologist) in each of the cases is classified as a supervisory service to the hospital rather than a physician service to an individual patient and is not payable under the physician fee schedule.

NOTE:   If Teaching Physician is involved in two surgeries, he or she must have a named backup who is a qualified surgeon, not a resident.

IV. DEFINITIONS

Resident means an individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary. Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of "resident". Additionally, this status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents.

A student means an individual who participates in an accredited educational program (e.g., a medical school) that is not an approved GME program. A student is never considered to be an intern or a resident. Medicare does not pay for any service furnished by a student. See Section II. for a discussion concerning E/M service documentation performed by students.

Critical or key portion means that part (or parts) of a service that the teaching physician determines is (are) a critical or key portion(s). For purposes of this section, these terms are interchangeable.

Documentation means notes recorded in the patient's medical records by a resident, and/or teaching physician or others as outlined in specific situations (section I) regarding the service furnished. Documentation may be dictated and typed, hand-written or computer-generated, and typed or handwritten. Documentation must be dated and include a legible signature or identity.   Pursuant to 42 CFR 415.172(b), documentation must identify, at a minimum, the service furnished, the participation of the teaching physician in providing the service, and whether the teaching physician was physically present.

Physically present means that the teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.

If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at nwt@ufl.edu.

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

---

Webmaster<ahagan@dean.med.ufl.edu>College of Medicine, Office of Compliance  This page created January 06, 2003..  Maintenanced 02/15/06 Please read our disclaimer and permitted use statement.