Practice Economics

Know What to Document


 

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:

Code This Case

The hospitalist rounds on a patient with the medical student. The student obtains a history, performs an exam and outlines the assessment and plan associated with the visit. The teaching physician supervises the entire service by the medical student. How should this service be reported?

the solution

Per Medicare guidelines, students (e.g., medical, nurse practitioner, etc.) may document services in the medical record. However, the teaching physician only may refer to medical student documentation associated with the review of systems and/or past/family/social history. The teaching physician may not refer to a student’s personal note for documentation of physical exam findings or medical decision making.

If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness, as well as perform and redocument the physical exam and medical decision making activities of the service. The teaching physician then selects the visit level most reflective of the performed and documented service.

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.

Medicare Definitions for Teaching Services

Critical or Key Portion: The part, or parts, of a service the teaching physician determines are critical or key. For purposes of this section, these terms are interchangeable.

Direct Medical and Surgical Services: To individual beneficiaries that are either furnished by a physician or by a resident under the supervision of a physician in a teaching hospital.

Physically Present: The teaching physician and the patient are in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) and/or the physician performs a face-to-face service.

Resident: An individual who participates in an approved graduate medical education (GME) program or a physician 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 approved for purposes of direct GME payments made by the fiscal intermediary (FI). Receiving a staff or faculty appointment or participating in a fellowship does not, by itself, alter the status of resident. This status remains unaffected regardless of whether a hospital includes the physician in its full-time-equivalency count of residents.

Student: An individual who participates in an accredited educational program at a medical school that is not an approved GME program. A student is never considered an intern or a resident. Medicare does not pay for any service furnished by a student.

Teaching Hospital: A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry or podiatry.

Teaching Physician: A physician (other than a resident) who involves residents in the care of his or her patients.

Teaching Setting: Any setting in which the FI makes Medicare payments for the services of residents under the direct graduate medical education payment methodology.

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:

  • Critical-care services (CPT codes 99291-99292);
  • Hospital discharge day management (CPT codes 99238-99239);
  • E/M codes in which counseling and/or coordination of care dominates (more than 50% of) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service; and
  • Prolonged services (CPT codes 99358-99359).

Surgical Services

Surgical services, which are defined as minor or major, also are subject to teaching physician rules. Teaching physician regulations identify minor procedures as those that take five minutes or less to complete and involve relatively little decision making once the need for the service is determined. Appropriate billing and payment hinges on the teaching physician’s presence for the entire procedure. Documentation should include a statement of presence, written and signed by the teaching physician.

Services that require more than five minutes are considered major surgical services, requiring teaching physician presence only during the (physician-determined) critical and key portions of the procedure. However, the teaching physician must be available to return to the procedure area during the surgery’s entirety, and not be involved in another procedure. Arrangements must be made to have another qualified physician available should the teaching physician get called away. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is on the faculty of SHM’s inpatient coding course.

References:

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

2. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2, www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.

3. Centers for Medicare & Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents, www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf.

4. Manaker, S. Teaching Physician Regulations. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008; 279-285.

5. Pohlig, C. Evaluation & Management Services: An Overview. Coding for Chest Medicine 2008, American College of Chest Physicians, 2008;57-69.

6. American Medical Association. cpt® 2008, Current Procedural Terminology Professional Edition. American Medical Association, 2007; 9-16.

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