Medicare Clarifies Teaching Physician E&M Documentation Guidelines
In November 2002, Medicare revised their Teaching Physician Documentation Guidelines making it clear that for Evaluation and Management (E&M) services, teaching physicians need not repeat the resident/fellow’s documentation.
Physician services in a teaching setting are paid by Medicare only if they
- are personally provided by a physician who is not a resident/fellow,
- are rendered jointly by a teaching physician and a resident/fellow, or
- are provided by a resident/fellow in the presence of a teaching physician.
For the purposes of this document, fellows are considered residents.
For E&M billing purposes, teaching physicians must personally document at least the following:
- That they performed the service or were physically present (located in the same room or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) during the key or critical portions of the service when performed by the resident; and
- Their participation in the management of the patient
Code selection should be based on the combined documentation of the resident and the teaching physician. Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the teaching physician presence and participation.
If you would like further information or are interested in examples of how these guidelines are applied, please call Neil Walsh in the Billing Compliance Department at 617-732-9377.