Teaching Physician Payment Regulations Under the Medicare
Part B Program; Billing for the Services of Resident and Fellows
in Their Own Name
February 9, 1998
Jordan J. Cohen, M.D.
President
Association of American Medical Colleges
2450 N Street, NW
Washington, DC 20037-1127
Dear Dr. Cohen:
I am responding to your letter dated January 28, outlining
your Association's concerns with the Evaluation and Management
(E/M) Documentation Guidelines particularly in regard to their
effect on the teaching physician rules. We met with your senior
staff on these issues last week and the importance of these
issues to your Association was clearly expressed.
Let me address two primary concerns. First of all, the E/M
Documentation Guidelines do not override the teaching physician
rules which became effective July 1, 1996. Teaching physicians
are not required to personally document the elements of the
examinations that are specified in the Documentation Guidelines.
For example, in cases where the teaching physician was present
during the entire time of the resident's exam, the extent
of the exam is based on the exam performed by the resident
in the presence of the teaching physician. To bill the highest
level, the entire comprehensive exam must be performed by
the resident in the presence of the teaching physician. The
teaching physician must personally perform those elements
of the exam that he/she considers to be key elements. In this
situation, the teaching physician does not have to personally
perform all elements of a comprehensive exam as is required
when the teaching physician examines the patient without the
resident present.
Documentation by the teaching physician can be limited. At
a minimum, the record must include a confirmation of the resident's
documentation and also the teaching physician's summary comments
which revise or confirm the findings of the resident's physical
exam, discussion of the history and medical decision-making.
The combined entries must be adequate to substantiate the
level of service required by the patient and the service code
billed.
The second major concern is the use of templates. Any format
or method used by the physician for documenting the encounter
is acceptable as long as the supportive information pertaining
to a level of service can be understood from a review of the
medical record. It is acceptable to write "negative"
or place a check mark in a designated column for an element
with normal findings. Comments on abnormal, unexpected findings
and pertinent information must be recorded.
At the request of the American Medical Association (AMA)
we delayed the implementation of the revised guidelines until
July 1, 1998. We believe that this additional time will enable
the physician community to become more familiar with the new
guidelines. This respite also will allow the medical specialty
societies to work together with the AMA and HCFA staff to
continue to refine the single system E/M Documentation Guidelines
and lessen the burden perceived by physicians. We welcome
and encourage the involvement of AAMC in this process. I am
hopeful that a reduction of the burden can be achieved without
hindering our requirements that the level of E/M services
billed must be medically necessary and supported by documentation
in the patient's medical record.
For your information, the AMA has already solicited comments
from the specialty societies and requested specific recommendations
for revisions to the guidelines. The AMA CPT Editorial Panel
will devote a major portion of the February, May and if necessary,
August meetings to the subject of refining guidelines based
on medical society recommendations. The AMA also is hosting
a one day "fly-in" in Chicago on April 27.
We will reinforce the information stated above on the teaching
physician rules and the use of templates with our regional
offices and carrier staff. Thank you for your continued support
of our efforts to standardize documentation for E/M services.
Sincerely,
Barton C. McCann, M.D.
Executive Medical Officer
Plan and Provider Purchasing Policy Group
Center for Health Plans and Providers
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