Documenting guidelines prevents future audits
Like many government guidelines, requirements for billing services supervised by teaching physicians are never as cut and dried as they seem. In an effort to help make federal guidelines in this area less murky, the American Society of Internal Medicine has developed a few general tips:
Medical records.
A patient’s medical record must include documentation to substantiate the claim submitted. However, unless specifically requested, the teaching physician does not have to submit these records with the claim.
Modifiers.
Teaching physicians must use the GC-modifier with a claim to indicate that a resident was involved in the service provided. Otherwise, the Health Care Financing Administration (HCFA) assumes it was provided exclusively by the physician and that no resident was involved.
Evaluation and management services.
Teaching physicians must perform and document in the patient’s record the necessary work to bill for an evaluation and management (E&M) service. However, they do not have to redocument all the information that the resident has already entered in the record.
Teaching physicians must review the system relevant to the patient’s current illness and document the major findings from the system review and exam. However, they do not need to perform a complete review of all systems or repeat documentation for the review of systems and past family and social history that the resident has already provided.
Teaching physicians must include summary notes of the key elements of the service (history of present illness, exam, and medical decision making such as diagnosis and plan of care) in the patient’s record. This combined documentation in the patient’s medical record by the resident and teaching physician will be used to substantiate the level of services billed.
Ambulatory care exception.
There is an exception for ambulatory care entities that receive intermediary payments based in part on time spent by residents in patient care activities. These facilities must also provide acute care of undifferentiated problems or chronic care for ongoing problems, coordination of care, and comprehensive care, which is not limited by organ system or diagnosis.
Under this exception, residents can bill for E&M services for levels one through three only. Any resident furnishing a service without a teaching physician present must have completed more than six months of an approved residency program. A teaching physician may supervise up to four residents at a time and must be immediately available to assume management responsibility for patients seen by residents in the ambulatory care facility.
Procedures.
The record for a minor procedure taking less than five minutes must document that the attending physician was physically present for the entire procedure. The record for a claim for other procedures must document that the attending physician was physically present for the key portion of the procedure.
Critical care services.
Claim records must document the physical presence of the teaching physician for the entire period indicated by the critical care code.
Signature and proxy stamps.
Signature stamps and electronic signatures are acceptable for noting who provided the service. Proxy stamps for covering physicians are also acceptable.
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