New guidance from the Centers for Medicare & Medicaid Services (CMS) affects how teaching physicians should document evaluation and management (E/M) services. The CMS described this change in policy in the Medical Learning Network Matters article MM11171 published this month.
First, let’s look back at what CMS stated in the 2019 Final Rule:
- The medical records must document that the teaching physician was present at the time the service is furnished. Additionally, the revised paragraph would specify that the presence of the teaching physician during procedures and E/M services may be demonstrated by the notes in the medical records made by a physician, resident, or nurse.
- The medical record must document the extent of the teaching physician’s participation in the review and direction of services furnished to each beneficiary, and that the extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by a physician, resident, or nurse.
- The teaching physician continues to be responsible for reviewing and verifying the accuracy of notations previously included by residents and members of the medical team, along with further documenting the medical record if the notations previously provided did not accurately demonstrate the teaching physician’s involvement in an E/M service.
Our recommendation at that time was that teaching physicians should continue to follow the documentation principles as outlined in MCM 1711 that required the teaching physician must at a minimum personally document that they performed the service or were physically present during the critical or key portions of the service furnished by the resident and specifically their participation in the management of the patient.
Now, with CMS’ release of information regarding Change Request 11171, it’s important for teaching physicians who bill Medicare Administrative Contractors (MACs) to note the following clarifications for documentation of E/M services for payment purposes:
- For the purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:
- that the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and
- the participation of the teaching physician in the management of the patient.
- The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.
This means that the teaching physician’s performance and/or presence during the key or critical portions of the service when performed by the resident can be documented by the resident or nurse. The teaching physician no longer has to document their own note. This is similar to previous guidance given by CMS in relation to medical student documentation.
CMS’ official instruction, CR11171, issued to your MAC regarding this change is available for review. The implementation date is set for July 29.
MedData’s team of experts and I are available to discuss these changes. You can reach out to me directly.