Transcript Jeffrey Linzer Sr., MD, MICP, FAAP, FACEP Associate Medical

Teaching physician rules
Jeffrey Linzer Sr., MD, MICP, FAAP, FACEP
Associate Medical Director for Business Affairs & Compliance
Emergency Pediatric Group
Children’s Healthcare of Atlanta at Egleston & Hughes Spalding
Assistant Professor of Pediatrics and Emergency Medicine
Emory University School of Medicine
Atlanta, Georgia
Teaching physician rules
• Based on Medicare guidelines
• Generally accepted and used by Medicaid and
commercial payers
• non-Medicare providers are not obligated to
follow the rule
• Fellows are considered residents
• whether program is ACGME approved or not
• some non-Medicare payers will exempt fellows
from some or all of the rules
Teaching physician
• Teaching physician must show personal
involvement in the
• evaluation
• development of the plan of care
• and treatment of the patient
• must be clearly defined as the attending physician
• Cannot just co-sign resident note
• “agree with above and plan as written”
Teaching physician documentation
• The teaching physician does not need to redocument the H&P
• Must write a note personalized for that patient that
shows that the teaching physician
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has examined the patient
has reviewed the resident’s note
has reviewed the plan of care as written
notes any modifications to resident’s findings or plan of
care
• The combination of the resident and teaching
physician note may be used to determine the level of
documentation
Examples of ‘minimally acceptable
documentation”
• Patient seen at same time with resident
• “I was present with resident during the history
and exam. I discussed the case with the resident
and agree with the findings and plan as
documented in the resident’s note.”
• “I saw the patient with the resident and agree with
the resident’s findings and plan.”
Examples of ‘minimally acceptable
documentation”
• Patient with or without the resident with the
teaching physician independently performing
the critical or key portion(s) of the service
• “I saw and evaluated the patient. Discussed with
resident and agree with resident’s findings and
plan as documented in the resident’s note.”
• “I saw and evaluated the patient. I reviewed the
resident’s note and agree, except that picture is
more consistent with bronchiolitis then asthma.
Will defer steroids.”
Examples of unacceptable documentation
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“Agree with above.”
“Discussed with resident. Agree.”
“Seen and agree.”
“Patient seen and evaluated.”
A legible countersignature or identity alone to
the resident’s note
Teaching physician time based billing
• May only bill for the time the teaching
attending is actually present
• may not count time resident alone was providing
care
• same rules apply to non-employed NP’s, PA’s without
independent billing numbers
Teaching physician procedures
• Only needs to be present for the ‘key’ or ‘critical’
portion of any billable procedure
• for short procedures (<5 minutes) must be at the bedside
for entire procedure
• The determination as to what is the ‘key’ or ‘critical’
portion of the procedure is up to the teaching
physician
• The teaching physician must be immediately
available for the entire procedure
• must be in the unit where the procedure is performed
Medical students
• Are not residents
• even a ‘sub-intern’ may not be utilized as a
resident for documentation and billing purposes
• May only document ROS and PFSH in the
medical record
• May assist with procedures
• teaching physician may not bill for any procedure
exclusively performed by a medical student
Additional documentation
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Your impressions
Differential diagnosis
Re-evaluations
Impression of ancillary test results
Information obtained from sources other than
the primary historian
• Medical care provided prior to patient’s
arrival (EMS)