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Title: Disclaimer


1
Disclaimer
  • This presentation is intended only for use by
    Tulane University faculty, staff, and students.
    No copy or use of this presentation should occur
    without the permission of Tulane University.
    Tulane University retains all intellectual
    property interests associated with the
    presentation. Tulane University makes no claim,
    promise, or guarantee of any kind about the
    accuracy, completeness, or adequacy of the
    content of the presentation and expressly
    disclaims liability for errors and omissions in
    such content.

2
Linking to Resident Notes - Billing E/M Services
in Teaching Settings
  • Clarification of Documentation Requirements for
    E/M Services Billed by Teaching Physicians
  • CMS Section 15016 Effective 11/22/02

Print the Linking to Resident Notes Quiz Before
Viewing Presentation
3
Read Before Proceeding
Physicians and Staff may earn one compliance
credit by viewing this presentation, completing
the assessment, and faxing the assessment
to 504-988-7777 This presentation may be viewed
for compliance credit only once in a fiscal year
(July 1 - June 30). To check how many
compliance credits you have and to see which
training sessions you have completed, contact the
University Privacy and Contracting Office at
504-988-7721
4
It is the policy of TUMG to provide healthcare
services that are in compliance with all state
and federal laws governing its operations and
consistent with the highest standards of business
and professional ethics. Education for all TUMG
physicians is an essential step in ensuring the
ongoing success of compliance efforts.
5
This education is Part 6 of a 6-part series on
documenting and selecting the level of service
for outpatient visits. All presentations are
available on the Tulane University Privacy and
Contracting Office website http//tulane.edu/coun
sel/upco/billing-ed/
  • Part 1 Overview of Basic Principles
  • Part 2 Documenting a History
  • Part 3 Documenting an Exam
  • Part 4 Documenting Medical Decision Making
  • Part 5 Time-Based Codes
  • Part 6 Linking to Resident Notes

6
Focus of Presentation
  • To provide physicians and staff with an overview
    of the Medicare Teaching Physician Rule as it
    pertains to billing documentation guidelines for
    E/M services

7
Focus of Presentation
  • Discuss Medicare documentation guidelines with
    regard to linking to resident notes
  • Provide samples of linking notes

Link Link Link!
8
Evaluation and Management (E/M) Services
  • The language of the Teaching Physician Rule makes
    it clear that for E/M services, teaching
    physicians need not repeat documentation already
    provided by a resident.

9
E/M Guidelines are unchanged
  • For a given encounter, the selection of the
    appropriate level of E/M service should be
    determined according to the code definitions in
    the American Medical Associations Current
    Procedural Terminology (CPT) and any applicable
    documentation guidelines.

10
This presentation does NOT apply to Medicaid
Billing
  • LA Medicaid only requires that Teaching
    Physicians sign the resident notes.
  • No linking statement is required.

11
Documentation Guideline
  • A Teaching Physician (TP) must link to a Resident
    note IF the TP will be using documentation in the
    resident note to support the level of service and
    reimbursement

Link Link Link!
12
Documentation Guideline
  • For example, if a Teaching Physician relies on a
    resident to document any portion of an E/M
    service (HX-EX-MDM) , then a linking statement is
    needed to include the resident documentation in
    the documentation for the visit.

Link Link Link!
13
Medicare Documentation Guidelines
14
Medicare Documentation
  • Refers to notes recorded in the medical record by
    a resident, and/or teaching physician or others
  • May be dictated and typed, handwritten or
    computer-generated
  • Must be dated and include a legible signature or
    identity

15
Medicare Documentation
  • Must identify, at a minimum
  • the service furnished
  • participation of the teaching physician in
    providing the service
  • whether the teaching physician was physically
    present

16
Medicares General Instructions
  • When assigning codes to services billed by
    teaching physicians, reviewers will combine the
    documentation of both the resident and the
    teaching physician provided the TP
    appropriately linked to the resident
    documentation.

17
Medicares General Instructions Regarding
Teaching Physician Presence
  • For OUTPATIENT and INPATIENT E/M SERVICES, the
    resident cannot attest to a Teaching Physicians
    presence.
  • The TP must document his/her presence and
    participation in the plan of care.

18
Medicares General Instructions when using both
Resident and Teaching Physician notes to support
a level of service
  • On medical review, the combined entries into the
    medical record by the teaching physician and the
    resident constitute the documentation for the
    service and together must support the medical
    necessity.
  • NOTE The notes cannot be combined without a
    linking statement.

19
For purposes of payment, a Teaching
Physicianmust document
  • That he/she performed the E/M service or was
    physically present during the key or critical
    portions of the service when performed by the
    resident AND
  • His/Her participation in the management of the
    patient

20
The Teaching Physician Rule identifies three
Scenarios for E/M services performed in a
teaching setting
21
Medicares Minimally Acceptable Documentation
must support the necessity of the Teaching
Physicians
  • ? Presence
  • ? Participation
  • ? Plan of Care

22
Scenario I - Teaching Physician without resident
note
  • Teaching Physician personally performs all
    required elements of an E/M service w/o resident.

23
Scenario 1 Documentation without a resident
note
  • The teaching physician must document as he or she
    would document an E/M service in a non-teaching
    setting.
  • Level of Service and reimbursement would be
    determined by the physicians note alone.

24
Scenario 2 Teaching Physician and Resident see
patient together
  • 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.
  • The Teaching Physician links to the Residents
    documentation. The combined notes would support
    the level of service and the reimbursement.

25
Scenario 2 What the Teaching Physician Must
Document
  • Teaching physician must document that he/she was
    present during the performance of the critical or
    key portions of the service and that he/she was
    directly involved in the management of the
    patient.

26
Scenario 2 What the Documentation Must Support
  • For payment, the composite of the teaching
    physicians entry and the residents entry
    together must support
  • the medical necessity of the billed service and
  • the level of the service billed by the teaching
    physician.

27
Scenario 2 - Linking Statements Minimum
documentation examples.
  • Initial or follow-up visit 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
    residents note.
  • Follow-up Visits I saw the patient with
    the resident and agree with the residents
    findings and plan.

28
Scenario 3 Teaching Physician and Resident see
Patient At Different Times
  • In this practice scenario, the resident performs
    and documents some or all of the required E/M
    elements without the Teaching Physician. The
    Teaching Physician independently performs the
    critical or key portion(s) of the E/M service
    with or without the resident.

29
Scenario 3 Teaching Physician
Linking/Documentation Requirements
  • In this practice scenario, the Teaching
    Physicians documentation, in addition to linking
    to residents note, must reflect the following
  • that he/she personally saw the patient,
  • personally performed key or critical portions of
    the E/M service, and
  • participated in the management of the patient.

30
  • Teaching physicians note should link to the
    residents note when using the residents
    documentation for billing the E/M service.

Resident Note
TP Note
The Teaching Physician must write/dictate the
linking statements that allow his/her note and
the resident note to be combined as support for
the level of service and reimbursement
31
Scenario 3 - Minimum documentation examples.
  • Initial or follow-up visit I saw and evaluated
    the patient. Discussed with resident and agree
    with residents findings and plan as documented
    in the residents note.
  • Initial visit I saw and evaluated the patient.
    I reviewed the residents note and agree, except
    that picture is more consistent with pericarditis
    than myocardial ischemia. Will begin NSAIDS.
  • Follow-up visit See residents note for
    details. I saw and evaluated the patient and
    agree with the residents findings and plan as
    written.

32
Scenario 3 Documentation Alert!
  • Documentation that does not clearly establish
    that the teaching physician was present,
    evaluated the patient, and/or had any involvement
    in the plan of care is unacceptable.

33
Examples of UnacceptableDocumentation
  • Agree with above
  • Rounded, reviewed, agreed
  • Discussed with resident

34
Teaching physician notes must be linked to
resident notes
  • NOTE even if those notes were followed by a
    legible Teaching Physician signature, they would
    not meet minimum documentation guidelines.

35
What is missing?
  • None of the examples establish whether the
    physician was either
  • Physically present when resident performed some
    or all E/M elements OR
  • Whether the resident performed some or all E/M
    elements in the absence of the TP .

36
Medical Student Documentation of E/M Services
37
To refer to student documentation, the E/M
services must be performed in the physical
presence of a teaching physician or physical
presence of a resident. CMS, transmittal 1780,
page 15-12, 11/2002
38
Documentation Alert!
  • For billing purposes, the Teaching Physician may
    only refer to medical student documentation of
    the
  • ROS (Review of Systems)
  • and/or PFSH (Past Family/Social History).

39
Documentation Alert!
  • No Medical Student documentation of a
  • Chief Complaint,
  • History of Present Illness,
  • Exam, and/ or
  • Medical Decision-Making
  • can be used to support a level of service,
    regardless of whether the documentation was done
    under the supervision of a resident or Teaching
    Physician.

40
If a medical student documents E/M services, the
teaching physician 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.
CMS15016, page 15-12, 11/2002
Documentation Alert!
41
Summary of Teaching Physician Documentation
Requirements
42
No resident note
  • Teaching Physician documents as he/she would
    document any E/M service level of service and
    reimbursement determined solely by TPs note.

43
TP and Resident see patiently jointly
  • TP must establish/document his/her
  • Presence
  • Participation
  • Plan of Care
  • TP must link to residents note

Link Link Link!
44
TP and Resident see patient at different times
  • TP must establish
  • Presence
  • Participation Must state he/she personally
    performed the critical elements of the exam
  • Participation in the plan of care
  • TP must link to residents note

Link Link Link!
45
Medical Student Documentation
  • Medical Student Documentation that may be used
    for billing purposes under the teaching physician
    rule is limited to
  • Review of Systems
  • Past Family/Social History AND
  • The documentation must be done in the presence of
    a TP or resident

46
Medicare Payment Guidelines
  • For payment, the composite of the teaching
    physicians entry and the residents entry
    together must support the medical necessity of
    the billed service and the level of the service
    billed by the teaching physician.

Bottom Line If your residents note has
documentation that you intend to use as support
for the level of service you select, you must
link to that resident note.
47
Did you review your residents notes?
  • The Teaching Physician Guidelines stress that
    physicians must review resident notes.
  • Linking without reading the resident note may
    result in a documentation level of service
    mismatch.
  • TUMG physicians are responsible for selecting the
    level for their outpatient services.

Before you link read!
48
A Final Note
  • The TUMG Compliance Staff can assist with
    developing documentation templates and linking
    statements.
  • Assistance is Just an Email Away

49
Know who to contact
  • TUMG Business Services
  • Compliance Reporting Hotline 504-988-5142

50
Good Things Happen When You Know the Rules
The TUMG Compliance Staff serves as a resource to
Tulane Physicians for continuous education and
improvement that will encourage and support
consistent compliance with key payor requirements.
51
End of Presentation
To Earn One Compliance Credit Complete and Sign
the Teaching Physician E/M Documentation
Guidelines Quiz Fax to 504-988-7777
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