Hospitalists who work in teaching hospitals need to understand the teaching physician (TP) rules, to know what qualifies for payment and how to document to receive that payment. TP services are payable when they are furnished by a physician who is not a resident or a resident with a teaching physician physically present during the critical or key portions of the service.
This article will focus on the documentation guidelines for inpatient services provided by the hospitalist in a teaching setting.
Evaluation and Management Services
Teaching physicians participate in evaluation and management (E/M) services with residents in several different ways. Below, three scenarios discuss documentation requirements:
Scenario One: The Stand-Alone Service. In this scenario, the teaching physician independently performs the entire service (i.e., all required elements of the billed visit) though the resident also may have seen the patient that same day. The TP may choose to document as if the care took place in a non-teaching setting. This documentation stands alone and independently supports the reported visit level.
Alternatively, the teaching physician may use the resident’s note. He or she does this by first documenting involvement in patient management and performance of the critical or key portion(s) of the service, and then linking to the resident’s note. The teaching physician selects the visit level based on the combined documentation (i.e., that of the teaching physician and the resident).
When referencing resident documentation, the teaching physician should use Medicare-approved linkage statements. Common examples include the following:
- “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.”
- “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
- “I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder than documented, so I will obtain an echo to evaluate.”
Although all of these examples are acceptable, the last one best identifies the teaching physician’s involvement in patient management, which is a requirement of TP documentation.
Scenario Two: The Supervised Service. In this scenario, resident and teaching physician provide services simultaneously. The teaching physician either may supervise the resident’s performance of required service elements or personally perform some of them.