Medicare Documentation Requirements for Teaching Physicians
Medicare pays for physician services furnished in teaching settings only if:
- The services are personally provided by a physician who is not a resident; or
- The services are rendered jointly by a teaching physician and resident or by a resident in the presence of a teaching physician, with certain exceptions as provided below.
When residents participate, the teaching physician must document his/her presence and participation in the key portion(s) of the service in order to seek payment.
Documentation requirements for evaluation and management (E/M) Services, including initial hospital care, emergency department visits, office visits for new patients, office consultations, and hospital consultations include a personal notation by the teaching physician documenting his/her participation in the three key components (i.e., history, examination, and medical decision making). If repeating key components obtained previously and documented by residents, e.g., complete history and physical examination, teaching physicians’ documentation may be brief, summary comments related to the resident’s entry which confirm or revise the key elements of
- relevant history of present illness and prior diagnostic tests;
- major finding(s) of the physical examination;
- assessment, clinical impression, or diagnosis; and
- plan of care.
Documentation requirements for subsequent hospital care and office visits for established patients include personal notations by teaching physicians highlighting two of the three key components (history, physical examination, and medical decision making).
Surgical, high-risk, or other complex procedures require teaching physicians documentation of presence during all critical and key portions of the procedure and immediate availability to furnish services during the entire procedure. When teaching surgeons are present between the opening and closing of the surgical field a surgeon’s presence may be demonstrated by medical record notes by the physician, resident, or operating room nurse. (There is no required information that the teaching surgeon must enter into the medical record.)
Teaching anesthesiologists must document presence during all critical (or key) portions of the procedure, including induction and emergence.
Interpretation of diagnostic radiology and other diagnostic tests require documentation that interpretation was performed or reviewed by the teaching physician. If a resident prepares and signs the interpretation, teaching physicians must indicate that he/she personally reviewed the image and the resident’s interpretation and either agrees or edits the findings.
For procedure codes determined on the basis of time, including individual medical psychotherapy, critical care services, etc., the teaching physician must be present for the period of time for which the claim is made.
These Medicare teaching documentation guidelines are not all-inclusive. For further information call Neil Walsh in the Billing Compliance Department at 617-732-9377.