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teaching physician rules

Teaching Physician Rules

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teaching physician rules

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    1. Teaching Physician Rules Terry Reeves Executive Director of Institutional Compliance February 2003

    2. Teaching Physician Rules…… History of Teaching Physician Regulations Lobbying the change New Guidance – CMS Transmittal 1780 - overview and analysis of change What is the impact? What does not change? Questions and Answers

    3. History of the Teaching Physician Rules Federal government payment rules - First billing guidelines established in 1967 Revisited and the birth of Intermediary Letter 372 (IL 372) - Continued confusion - Lack of standard application of rules by local Medicare Carriers “New” Teaching Physician Rules – July 1, 1996 The Health Care Financing Administration (HCFA, now CMS) first established guidelines for billing practices of teaching physicians in 1967. The requirements were again addressed in 1969 when HCFA issued Intermediary Letter 372 (IL-372), which delineated the criteria to be met by teaching physicians before submitting a bill for payment of services. Questions continued to be raised about when and to what extent the physical presence of the teaching physician was required for billing Medicare. Adding to the confusion were the inconsistent interpretation and enforcement of the rules by local Medicare carriers. In December 1995, HCFA published new regulations, effective July 1996, that detailed when a teaching physician could appropriately bill Medicare for patient care services in which a resident also is involved. The regulations were intended to reduce substantially the ambiguities engendered by the previous HCFA guidelines. They require, with one narrow exception, that the teaching physician be present to perform or observe the “key portion” of any service or procedure for which payment is sought and provide further guidance on the documentation required in the medical record to substantiate that such services were performed. Son after the rules were issued, CMS also published a revised CMI to provide additional information needed to implement the new rules. Despite the increased clarity under the new rules and CMI, some of the documentation requirements were considered to be overly burdensome and impeded both the delivery of patient care services and the teaching process. CMS has been examining the regulatory burden on physicians and attempting to provide relief when feasible. Over the past year, the Agency has worked with AAMC through the Group on Faculty Practice Steering Committee to identify burdensome aspects of the supervising physician requirements that could be addressed through revisions to the Carrier Manual Instructions rather than through changes in the regulation. The revised CMI should significant reduce the documentation burden on the teaching physicians for E/M services when a resident also is involved in the care of a patient. It is important to note that with very limited exceptions, a teaching physician still must write a personal note and, unless the service is provided under the Primary Care Exception, must be present for the “key portion” of the service.The Health Care Financing Administration (HCFA, now CMS) first established guidelines for billing practices of teaching physicians in 1967. The requirements were again addressed in 1969 when HCFA issued Intermediary Letter 372 (IL-372), which delineated the criteria to be met by teaching physicians before submitting a bill for payment of services. Questions continued to be raised about when and to what extent the physical presence of the teaching physician was required for billing Medicare. Adding to the confusion were the inconsistent interpretation and enforcement of the rules by local Medicare carriers. In December 1995, HCFA published new regulations, effective July 1996, that detailed when a teaching physician could appropriately bill Medicare for patient care services in which a resident also is involved. The regulations were intended to reduce substantially the ambiguities engendered by the previous HCFA guidelines. They require, with one narrow exception, that the teaching physician be present to perform or observe the “key portion” of any service or procedure for which payment is sought and provide further guidance on the documentation required in the medical record to substantiate that such services were performed. Son after the rules were issued, CMS also published a revised CMI to provide additional information needed to implement the new rules. Despite the increased clarity under the new rules and CMI, some of the documentation requirements were considered to be overly burdensome and impeded both the delivery of patient care services and the teaching process. CMS has been examining the regulatory burden on physicians and attempting to provide relief when feasible. Over the past year, the Agency has worked with AAMC through the Group on Faculty Practice Steering Committee to identify burdensome aspects of the supervising physician requirements that could be addressed through revisions to the Carrier Manual Instructions rather than through changes in the regulation. The revised CMI should significant reduce the documentation burden on the teaching physicians for E/M services when a resident also is involved in the care of a patient. It is important to note that with very limited exceptions, a teaching physician still must write a personal note and, unless the service is provided under the Primary Care Exception, must be present for the “key portion” of the service.

    4. Teaching Physician Rules Lobbying for Change Association of American Medical Colleges (AAMC) Continuous lobbying efforts Group on Faculty Practice Steering Committee - CMS - Identify areas of “documentation burden”

    5. Teaching Physician Rules New Guidance – Transmittal 1780 Section 15016, Supervising Physicians in Teaching Settings The new/revised material focuses on three general areas: Definitions Payment of Teaching Physicians General Documentation Instructions and Common Scenarios

    6. What are the Laws that Govern Teaching Physician Rules? 42 CFR §415.172 (a) General rule. If a resident participates in a service furnished in a teaching setting, physician fee schedule payment is made only if a teaching physician is present during the key portion of any service or procedure for which payment is sought. 42 CFR §415.172 (a)(2) In the case of evaluation and management services, the teaching physician must be present during the portion of the service that determines the level of service billed.

    7. What are the Laws that Govern Teaching Physician Rules? 42 CFR §415.172 (b) The medical records must document the teaching physician was present at the time the service is furnished. The presence of the teaching physician during procedures may be demonstrated by the notes in the medical records made by a physician, resident, or nurse. In the case of evaluation and management procedures, the teaching physician must personally document his or her participation in the service in the medical records. 42 CFR §415.172 (c) In the case of services such as evaluation and management for which there are several levels of service codes available for reporting purposes, the appropriate payment level must reflect the extent and complexity of the service when fully furnished by the teaching physician.

    8. Presence & Participation The two significant principles of teaching physician documentation are presence & participation. Presence may not be inferred; it must be stated or “attested” by the teaching physician. Presence is defined in the new teaching physician guidelines.

    9. Presence & Participation Participation in the service provided to the patient is required. However no definition of participation is provided in the new teaching physician guidelines. In the past, participation was evidenced by documenting or re-documenting portions of the key components of an Evaluation & Management service. The new guidelines are allowing participation in the service to be evidenced by stating that the teaching physician has: Read a specific resident’s note, Confirmed the findings, if you weren’t present when the resident did the exam, and Agrees with the specific resident’s assessment and plan.

    10. Teaching Physician Rules - Definitions Physically Present is defined as meaning: When the teaching physician is located in the same room (or partitioned/curtained/subdivided areas) as the patient. Providing a face- to- face service Documentation Documentation means notes recorded in the patient’s medical records by a resident, and/or teaching physician or others regarding the service furnished to the patient. Documentation may be dictated and typed, hand-written, or computer-generated, and typed or hand-written. 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. Evaluation and Management (E/M) Services Evaluation and Management Services means services provided to patients that involve evaluation of the patient’s medical problem and the management of that problem. The following types of services constitute E/M Services: New and follow-up outpatient visits including outpatient consults New and follow up inpatient hospital visits including the admission history and physical Inpatient consults Hospital Observation Services Emergency Department Services but not including procedures Critical Care Services Physician services to patients in nursing homes Physician House calls Resident 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, residents, and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary. 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. Student 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 an intern or a resident. Medicare does not pay for any service furnished by a student. Teaching Physician Teaching physician means a physician (other than another resident) who involves residents in the care of his or her patients. Documentation Documentation means notes recorded in the patient’s medical records by a resident, and/or teaching physician or others regarding the service furnished to the patient. Documentation may be dictated and typed, hand-written, or computer-generated, and typed or hand-written. 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. Evaluation and Management (E/M) Services Evaluation and Management Services means services provided to patients that involve evaluation of the patient’s medical problem and the management of that problem. The following types of services constitute E/M Services: New and follow-up outpatient visits including outpatient consults New and follow up inpatient hospital visits including the admission history and physical Inpatient consults Hospital Observation Services Emergency Department Services but not including procedures Critical Care Services Physician services to patients in nursing homes Physician House calls Resident 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, residents, and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary. 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. Student 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 an intern or a resident. Medicare does not pay for any service furnished by a student. Teaching Physician Teaching physician means a physician (other than another resident) who involves residents in the care of his or her patients.

    11. Teaching Physician Rules for Evaluation & Management Services The teaching physician must 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 a resident. The participation of the teaching physician in the management of the patient. Reviewers will combine the documentation of both the resident and the physician.

    12. Teaching Physician Rules for Evaluation & Management Services 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 for an Evaluation & Management service. The combined entries into the medical record by the TP and the resident must support the medical necessity of the service.

    13. Teaching Physician Rules for Evaluation & Management Services Scenario 1 - TP personally performs all the required elements of an E/M service without a resident Scenario 2 – The resident performs the elements required for an E/M service in the presence of, or jointly with and the TP and the resident documents the service. Scenario 3 – The resident completes and documents the elements of the service, in the absence of the TP. The the TP performs the critical or key portion(s) independent of the resident (the resident may or may not be present).

    14. Teaching Physician Rules for Evaluation & Management Services Scenario 1 – The teaching physician personally performs all the required elements of an E/M service without a resident. In this scenario and in the absence of a note by a resident, the TP must document as he or she would document an E/M service in a non-teaching setting. Minimally acceptable documentation for Scenario 1 In the absence of a note by a resident, the teaching physician must document as he or she would document and E/M service in a non-teaching system.

    15. Teaching Physician Rules for Evaluation & Management Services Scenario 1 Minimally acceptable documentation for Scenario 1 Where a resident has written notes, the teaching physician’s note may reference the resident’s note. The teaching physician must document that he or she performed the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient. 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. “I saw and evaluated the patient. I agree with the findings and plan of care documented in the resident’s note.” TP must sign, date & time the note. “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.” TP must sign, date, & time the note. Example: The teaching physician sees the patient at 6:00 am in the morning. The teaching physician does a history, exam, and medical decision-making, or for an established patient the teaching physician does some combination of history, exam, and medical decision-making. At 8:00 am the resident sees the patient and also does a history, exam, and medical decision making. Later that day the teaching physician and the resident discuss the patient. The only service that can be reported is the service provided and documented by the teaching physician. Medicare requires that the patient be seen by the teaching physician together with the resident, i.e., elbow to elbow, or following the resident’s service in order to combine the teaching physician’s note/service with the note/service of the resident. Documentation Example: There would be a statement by the physician that said: ·        “Today I saw Mr. Patient in clinic or on the inpatient service.” The remainder of the teaching physicians note only would be used to determine the level of evaluation and management service. Because no note by a resident has been written, the teaching physician must document as he or she would document and E/M service in a non-teaching setting. Explanations/Recommendations: Through various communications with the Centers for Medicare and Medicaid Services (CMS) and other conferences, teaching physicians are encouraged to make statements using personal pronouns that indicate they personally performed services with patients and without any resident involvement. Statements that support this personal involvement include the following; ·        “Today I saw Mr. Patient on the inpatient service.” ·        “On my exam, the patient is afebrile.” Example: The teaching physician sees the patient at 6:00 am in the morning. The teaching physician does a history, exam, and medical decision-making, or for an established patient the teaching physician does some combination of history, exam, and medical decision-making. At 8:00 am the resident sees the patient and also does a history, exam, and medical decision making. Later that day the teaching physician and the resident discuss the patient. The only service that can be reported is the service provided and documented by the teaching physician. Medicare requires that the patient be seen by the teaching physician together with the resident, i.e., elbow to elbow, or following the resident’s service in order to combine the teaching physician’s note/service with the note/service of the resident. Documentation Example: There would be a statement by the physician that said: ·        “Today I saw Mr. Patient in clinic or on the inpatient service.” The remainder of the teaching physicians note only would be used to determine the level of evaluation and management service. Because no note by a resident has been written, the teaching physician must document as he or she would document and E/M service in a non-teaching setting. Explanations/Recommendations: Through various communications with the Centers for Medicare and Medicaid Services (CMS) and other conferences, teaching physicians are encouraged to make statements using personal pronouns that indicate they personally performed services with patients and without any resident involvement. Statements that support this personal involvement include the following; ·        “Today I saw Mr. Patient on the inpatient service.” ·        “On my exam, the patient is afebrile.”

    16. Teaching Physician Rules for Evaluation & Management Services 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.

    17. Teaching Physician Rules for Evaluation & Management Services Minimally acceptable documentation for Scenario 2 “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.” TP must sign, date, & time the note. “I saw the patient with the resident and agree with the resident’s findings and plan.” TP must sign, date, & time the note. Example: The teaching physician and the resident team are making rounds together at 10:00 a.m. The teaching physician and the resident(s) go into the patient room together and the teaching physician listens as the resident interviews the patient regarding the patient’s history. The teaching physician observes the resident examine the patient. The resident discusses with the teaching physician the assessment and plan for the patient. This discussion does not have to occur in the presence of the patient. It would be advisable for the teaching physician to do some sort of physical examination of the patient in order to confirm the resident’s examination. The exam by the teaching physician may certainly be brief but enough to confirm the key portion of the physical examination. Documentation Example: The resident would write a note in the patient’s record that discusses history, examination, and decision-making or some combination of these elements if this is an established patient. At a minimum the teaching physician would write a note that states the following. I have personally interviewed and examined Mr. Patient along with Dr. Resident. (The resident’s name should be stated.) I agree with the resident’s findings as stated in the resident’s note. The teaching physician should sign, date, and time their note. I was present with the resident during the history and physical examination. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note. The teaching physician should sign, date, and time their note. I saw the patient with the resident and agree with the resident’s findings and plan. The teaching physician should sign, date, and time their note. Explanations/Recommendations: In the audio-conference held on January 9, 2003 with the AAMC and representatives from CMS, CMS officials stated that if it is not patently obvious which resident wrote the note that the teaching physician is linking or referring to, then the teaching physician should write the name of the resident with whom he/she saw the patient. For example, on the inpatient service many different residents or a team of residents may provide service to the patient and write documentation in the patient’s medical record. The CMS officials indicated that the teaching physician must indicate to which note he/she is referring. Moreover, since the teaching physician is not required to state anything specifically about the key components, it is even more important that it is clear in the medical record to which note the teaching physician is referring. Example: The teaching physician and the resident team are making rounds together at 10:00 a.m. The teaching physician and the resident(s) go into the patient room together and the teaching physician listens as the resident interviews the patient regarding the patient’s history. The teaching physician observes the resident examine the patient. The resident discusses with the teaching physician the assessment and plan for the patient. This discussion does not have to occur in the presence of the patient. It would be advisable for the teaching physician to do some sort of physical examination of the patient in order to confirm the resident’s examination. The exam by the teaching physician may certainly be brief but enough to confirm the key portion of the physical examination. Documentation Example: The resident would write a note in the patient’s record that discusses history, examination, and decision-making or some combination of these elements if this is an established patient. At a minimum the teaching physician would write a note that states the following. I have personally interviewed and examined Mr. Patient along with Dr. Resident. (The resident’s name should be stated.) I agree with the resident’s findings as stated in the resident’s note. The teaching physician should sign, date, and time their note. I was present with the resident during the history and physical examination. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note. The teaching physician should sign, date, and time their note. I saw the patient with the resident and agree with the resident’s findings and plan. The teaching physician should sign, date, and time their note. Explanations/Recommendations: In the audio-conference held on January 9, 2003 with the AAMC and representatives from CMS, CMS officials stated that if it is not patently obvious which resident wrote the note that the teaching physician is linking or referring to, then the teaching physician should write the name of the resident with whom he/she saw the patient. For example, on the inpatient service many different residents or a team of residents may provide service to the patient and write documentation in the patient’s medical record. The CMS officials indicated that the teaching physician must indicate to which note he/she is referring. Moreover, since the teaching physician is not required to state anything specifically about the key components, it is even more important that it is clear in the medical record to which note the teaching physician is referring.

    18. Teaching Physician Rules for Evaluation & Management Services 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 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.

    19. Teaching Physician Rules for Evaluation & Management Services Minimally acceptable documentation for Scenario 3 “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 NSAID’s.” TP must sign, date, & time note. “I saw and evaluated the patient. Discussed with resident’s findings and plan as documented in the resident’s note,” TP must sign, date, & time the note. “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans as written.” TP must sign, date, & time the note. “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. “ TP must sign, date, & time the note. Example: The resident sees the patient at 7:00 am in the morning, provides clinical service to the patient and documents history, examination, and medical decision-making or some combination of history, examination, and medical decision-making if this is an established patient. The teaching physician conducts teaching rounds with the resident team and discusses each patient with residents in conference, but did not go to the patients’ rooms and examine each patient. The teaching physician sees and examines the patient at 7:00 pm in the evening. Documentation Example: The resident would write a note in the patient’s record that discusses history, examination, and decision-making or some combination of these elements if this is an established patient. At a minimum, the teaching physician would write a note that states the following. ·        “I have personally interviewed and examined Mr. Patient. I reviewed the resident’s (name the specific resident) note and agree except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.” The teaching physician should sign, date, and time their note. ·        “I saw and evaluated the patient. Discussed with the resident and agree with resident’s findings and plan as documented in the resident’s note.” The teaching physician should sign, date, and time their note. ·        “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans as written.” The teaching physician should sign, date, and time their note. ·        “I saw and evaluated the patient. I have discussed the patient’s care with the resident and agree with the resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.” The teaching physician should sign, date, and time their note. Explanations/Recommendations: The teaching physician must document their personal presence with patient. The teaching physician must examine the patient because he did not participate in this activity when performed by the resident and in order to agree with the resident’s findings, the teaching physician would have to verify the resident’s findings. It would be questionable if the teaching physician never needed to revise a resident’s physical examination. Because the resident and teaching physician did not see the patient together, the teaching physician must document the discussion regarding the patient’s plan of care. If it is not patently obvious which resident wrote the note that the teaching physician is referring to, then the teaching physician should write the name of the resident with whom he/she saw the patient. For example on the inpatient service many different residents or a team of residents may provide service to the patient and write documentation in the patient’s medical record. CMS officials indicated that the teaching physician must indicate to which note he/she is referring. Moreover, since the teaching physician is not required to state anything specifically about the key components, it is even more important that the medical record is clear regarding to which note the teaching physician is referring. Example: The resident sees the patient at 7:00 am in the morning, provides clinical service to the patient and documents history, examination, and medical decision-making or some combination of history, examination, and medical decision-making if this is an established patient. The teaching physician conducts teaching rounds with the resident team and discusses each patient with residents in conference, but did not go to the patients’ rooms and examine each patient. The teaching physician sees and examines the patient at 7:00 pm in the evening. Documentation Example: The resident would write a note in the patient’s record that discusses history, examination, and decision-making or some combination of these elements if this is an established patient. At a minimum, the teaching physician would write a note that states the following. ·        “I have personally interviewed and examined Mr. Patient. I reviewed the resident’s (name the specific resident) note and agree except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.” The teaching physician should sign, date, and time their note. ·        “I saw and evaluated the patient. Discussed with the resident and agree with resident’s findings and plan as documented in the resident’s note.” The teaching physician should sign, date, and time their note. ·        “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans as written.” The teaching physician should sign, date, and time their note. ·        “I saw and evaluated the patient. I have discussed the patient’s care with the resident and agree with the resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.” The teaching physician should sign, date, and time their note. Explanations/Recommendations: The teaching physician must document their personal presence with patient. The teaching physician must examine the patient because he did not participate in this activity when performed by the resident and in order to agree with the resident’s findings, the teaching physician would have to verify the resident’s findings. It would be questionable if the teaching physician never needed to revise a resident’s physical examination. Because the resident and teaching physician did not see the patient together, the teaching physician must document the discussion regarding the patient’s plan of care. If it is not patently obvious which resident wrote the note that the teaching physician is referring to, then the teaching physician should write the name of the resident with whom he/she saw the patient. For example on the inpatient service many different residents or a team of residents may provide service to the patient and write documentation in the patient’s medical record. CMS officials indicated that the teaching physician must indicate to which note he/she is referring. Moreover, since the teaching physician is not required to state anything specifically about the key components, it is even more important that the medical record is clear regarding to which note the teaching physician is referring.

    20. Teaching Physician Rules for Evaluation & Management Services The following are examples of unacceptable TP linking statements: Agree with above Rounded, reviewed and agree Discussed with resident. Agree. Seen and agree. Patient seen and evaluated Countersignature alone

    21. Teaching Physician Rules for Evaluation & Management Services Unacceptable documentation CMS states: “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.”

    22. Teaching Physician Rules for Evaluation & Management Services Unacceptable documentation Do not contain a statement of TP presence. Do not reference the resident’s note. No evidence of participation in the service to the patient.

    23. Teaching Physician Rules for Evaluation & Management Services General documentation principles for teaching physicians Documentation by a teaching physician 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. Documentation must be dated. Documentation must be timed (required by UTMB Medical Staff Bylaws) Documentation must include a legible signature or identity.

    24. E/M Service Documentation Provided by Students Student documentation to which the physician may refer to is limited to the review of systems, and past, family, and social history. The TP may not refer to the student’s documentation of physical exam findings or medical decision making. If the student documents the E/M services, the TP 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.

    25. What is the Impact? Transmittal 1780 clarifies documentation requirements with specific definitions and scenarios. The revised language makes it clear for E/M services that the TP need not repeat the documentation already provided by the resident. Clarifies the policy for services performed and documented by medical students.

    26. What is the Impact? For E/M services, it is no longer required that the TP document a patient-specific comment related to the history, exam, and medical decision making as required by the code category. The requirements for TP presence during the critical and key portions of both E/M services and surgical procedures has not changed. Physicians now have specific examples of minimally acceptable documentation for common E/M scenarios.

    27. To Whom Do these Rules Apply? These guidelines apply to medical residents only, those individuals with an M.D. or D.O. degree that meet the definition of a resident. These guidelines do not apply to any other health care service provider other than teaching physicians and residents. They do not apply to any kind of student: Nursing, PA, Nurse Practitioner Psychology or otherwise. They do not apply to Advance Practice Nurses or Physician’s Assistants They do not apply to nurses. They do not apply to anyone else other than those individuals meeting the definition of a medical resident. These guidelines apply to medical residents only, those individuals with an M.D. or D.O. degree only that meet the definition of a resident. These guidelines do not apply to any other healthcare service provider other than residents. ·        They do not apply to any kind of student: Nursing, PA, Nurse Practitioner, Psychology, or otherwise. ·        They do not apply to Advanced Practice Nurses or Physician’s Assistants ·        They do not apply to nurses. ·        They do not apply to anyone else other than those individuals meeting the definition of resident. These guidelines apply to medical residents only, those individuals with an M.D. or D.O. degree only that meet the definition of a resident. These guidelines do not apply to any other healthcare service provider other than residents. ·        They do not apply to any kind of student: Nursing, PA, Nurse Practitioner, Psychology, or otherwise. ·        They do not apply to Advanced Practice Nurses or Physician’s Assistants ·        They do not apply to nurses. ·        They do not apply to anyone else other than those individuals meeting the definition of resident.

    28. What does not change? The former teaching physician guidelines continue to apply for Surgery Anesthesia Time-Based Codes Endoscopy Psychiatry Procedures Diagnostic Test Interpretations and Radiology

    29. Is Physician Re-Education Necessary? Yes The examples provided regarding the three E/M scenarios are examples of “minimally acceptable documentation.” The possibility of ambiguous entries still exists. It still must be clear that the physician personally evaluated the patient and through that evaluation confirms the findings of the resident. Online training will be available shortly.

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