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.

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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
504-988-7739
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.
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This education is Part 8 of a 9-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 Documenting Consults

• Part 6 Documenting Pre-Operative and
  Confirmatory Consults
• Part 7 Time-Based Codes
• Part 8 Linking to Resident Notes
• Part 9 Modifiers 24 25

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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 revised language of the Teaching Physician
  Rule (November 2002) makes it clear that for E/M
  services, teaching physicians need not repeat
  documentation already provided by a resident.

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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!
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Documentation Alert 1
If the Teaching Physician does NOT link to the
residents documentation of the E/M service, AND
the TP does not re-document the E/M elements in
his/her own note, the history component of an E/M
service could not be counted as support for a
level of service.
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Not Linking To Residents Notes May Affect The
Level of Service and Reimbursement

• New Patient and Initial Consult E/M Services
  requires all three E/M Key Components be
  documented
• History
• Exam
• Medical Decision Making

• Without a linking note, a Teaching Physician who
  relies on a resident to document any elements of
  an E/M service would not be able to bill for
• A New Patient Visit
• An Initial Consult

Without linking to the resident documentation OR
re-documenting the history in his/her own note,
the Teaching Physician could only bill for an
Established Patient E/M service.
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Medicare Documentation Guidelines
16
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

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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

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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 linked to
  the resident documentation.

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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.

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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.

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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

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The Teaching Physician Rule identifies three
Scenarios for E/M services performed in a
teaching setting
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Medicares Minimally Acceptable Documentation
must support the necessity of the Teaching
Physicians

• ? Presence
• ? Participation
• ? Plan of Care

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Scenario I - Teaching Physician without resident
note

• Teaching Physician personally performs all
  required elements of an E/M service w/o resident.

25
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.

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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.

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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.

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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.

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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.

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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.

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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.

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• 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
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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.

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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.

35
Examples of UnacceptableDocumentation

• Agree with above
• Rounded, reviewed, agreed
• Discussed with resident

36
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.

37
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 .

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Medical Student Documentation of E/M Services
39
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
40
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).

41
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.

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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!
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Summary of Teaching Physician Documentation
Requirements
44
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.

45
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!
46
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!
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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

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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.
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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!
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GO TO THE SOURCE

• Transmittal 1780, Supervising Physicians in
  Teaching Settings, can be found on the CMS
  (Center for Medicare and Medicaid Services)
  website
• http//www.med.ufl.edu/complian/Qa/CMS_Transmitta
  l_R1780B3.pdf

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A Final Note

• The TUMG Compliance Staff can assist with
  developing documentation templates and linking
  statements.
• Assistance is Just an Email Away

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Know who to contact

• TUMG Business Services
• Compliance Reporting Hotline [phone]

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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.
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End of Presentation
To Earn One Compliance Credit Complete and Sign
the Teaching Physician E/M Documentation
Guidelines Quiz Fax to 504-988-7777