ED Coding Update

Avoid common missteps when billing for the services provided by teaching physicians

[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]

Billing for the services provided by teaching physicians (TPs) continues to create problems for providers, coders, and compliance professionals due the many faces of documentation provided through electronic medical records (EMRs), template records, and handwritten charts. To better understand the elements of service and documentation required for the TP to bill independently for services provided in collaboration with a resident, it might be helpful to review some common definitions.


A teaching physician is a physician (other than another resident) who involves residents in the care of his or her patients.

A resident is 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 and fellows in GME programs recognized as approved for purposes of direct GME payments made by the financial institution. Receiving a staff or faculty appointment or participating in a fellowship does not, by itself, alter the status of "resident." Additionally, this status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents.

A student is 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 to be an intern or a resident. Medicare does not pay for any service furnished by a student. (See E/M service documentation performed by students.)

Being physically present is when the TP is located in the same room (or a partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the TP and/or resident performs a face-to-face service.

Documentation requirements

When notes are dictated by a resident and/or TP or others as outlined in the specific situations below, Medicare documentation guidelines are as follows:

• Documentation may be dictated and typed or handwritten, or computer-generated and typed or handwritten. Documentation must be dated and include a legible signature or identity. Documentation must identify, at a minimum, the service furnished, the participation of the TP in providing the service, and physical presence of the TP to assess the patient and participate in the plan of care.

Dictation "macros" are acceptable for attestations in the context of an electronic medical record. When using an EMR, it is acceptable for the TP to use a macro as the required personal documentation if the TP adds it personally in a secured (password-protected) system. In addition to the TP's macro, either the resident or the TP must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. According to Medicare, it is insufficient documentation if both the resident and the TP use macros.

Medicare Teaching Physician E/M Documentation Requirements

E/M services billed by TPs require personal documentation of at least the following:

• Personal performance of the service or documentation of physical presence during the key or critical portions of the service when performed by the resident; and

• The participation of the TP in the management of the patient.

Note: When assigning codes to services billed by TPs, coders should combine the documentation of both the resident and the TP for selecting the appropriate E/M service.

A Medicare example of minimally acceptable documentation by the TP is: "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."

Each attestation or addendum must be patient-specific and identify that the TP was physically present and evaluated the patient or had involvement with planning the patient's care. If the TP attestation or addendum isn't dictated/documented, then services are not separately billable by the TP. (Medicare considers funds provided to the hospital on the Part A side appropriate reimbursement for the teaching duties of the TP, so separately billing for services that do not include a personal involvement and face-to-face visit with the patient would be considered inappropriate.)

Medicare examples of unacceptable documentation by the teaching physician 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.

Such documentation is not acceptable because the documentation does not make it possible to determine whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care. In cases in which there is no direct TP involvement and documentation of content of that personal involvement, the record is unbillable.

Resident E/M documentation requirements

Residents can document all components of an E/M service under the supervision of the TP. Resident notes and TP notes can be dictated separately. When determining E/M level, coders must combine both resident and TP documentation. However, services without a TP attestation of personal involvement or addendum indicating personal involvement with the patient are unbillable.

Medical student E/M documentation requirements

When the TP is billing separately for services provided with the assistance of medical students, only the following can be performed by the medical student and, if reviewed and agreed to by the TP, can be counted as part of the TP's service:

• Review of systems; and

• Past, family, and social history.

Medical students often document in ED records. However, in order for medical students to document the above items, the TP and/or resident must be physically present to qualify for TP services.

The TP may not refer to a student's documentation of physical exam findings or medical decision making in his or her personal note. If the medical student documents 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.

Teaching physician documentation requirements for time-based E/M services

According to Medicare rules for Critical Care Services, the TP must be present for the period of time for which the claim is made. None of the time spent by the resident unaccompanied by the TP can count toward critical care. For example, code 99291 requires 30-74 minutes spent evaluating a critically ill or injured patient. Although it is common for the resident to be involved in managing critically ill patients, the TP must be physically present with or without the resident for 30- 74 minutes to report Critical Care Service code 99291. Time spent by the resident alone cannot count toward critical care time billed separately by the TP.

Examples of Critical Care Attestations:

Unacceptable Example of Documentation:

"I came and saw (the patient) and agree with (the resident)."

Acceptable Example of Documentation:

"Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care."

Teaching physician surgical procedure documentation requirements

In order for TPs to bill for minor procedures performed by residents in the ED, the TP must be present during the entire procedure, even for those that take only a few minutes to complete. These procedures are defined as taking five minutes or less (e.g., simple suture), and involve relatively little decision-making once the need for the operation is determined. For more complicated procedures, the TP must be present for the entire procedure to bill independently for a procedure involving a resident. For more complex procedures, the TP must be present for the "key" portions, determined by what the TP considers "key" and based on the type of procedure.

Procedure notes can be documented by the resident. However, the TP must dictate an attestation or addendum stating that he or she was present during the entire procedure for minor procedures and for the "key" elements for more complex procedures by documenting the key portions of the procedure for which he or she was present.

Interpretation of diagnostic radiology and other diagnostic tests

Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a TP. If the TP's signature is the only signature on the interpretation, Medicare assumes that he or she is indicating that he or she personally performed the interpretation. If a resident prepares and signs the interpretation, the TP must indicate that he or she has personally reviewed the image and the resident's interpretation and either agrees with or edits the findings. Medicare does not pay for an interpretation if the TP only countersigns the resident's interpretation.

Documentation Tip: If using macros, TPs should have two different attestations: One for E/M services and the other for Procedures performed in the ER.

Teaching Physician E/M & Procedure Coding and Billing Tips

• Resident notes must have a TP attestation or addendum. If not, the service is unbillable.

• Resident notes must have a signature by the TP to meet federal and facility policies, whether or not the TP personally provided a billable service. You must differentiate the physician attestation, which illustrates review and agreement with the resident's service from the separately billable service provided and billed separately by a TP. All resident charts must be reviewed and signed by the supervising TP, but that alone does not demonstrate performance of a separately billable service by the TP.

• If E/M or procedure meets Medicare TP guidelines (Medicare/ Medicare HMO only) — GC modifier must be appended to each service line item that residents participate in.

• When coding Critical Care Services, only time spent by the TP is counted toward billable critical care time.