Know What to Document

The Hospitalist. 2008 October;2008(10):

October 1, 2008|The Hospitalist

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.