Definitions:

Teaching Physician:
Physician (other than another resident) who involves residents in the care of his or her patients.

Resident:
An individual in an approved graduate medical education (GME) program or a physician who is authorized to practice only in a hospital setting. (an M.D. only)

Physically Present:
The teaching physician must be located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.

Critical or Key Portion:
That part (or parts) of a service that the teaching physician determines is (are) a critical or key portion(s).

Rules Pertaining to Documentation:

Surgical Procedures: If a resident participates in a service furnished in a teaching setting, physician fee schedule payment is made only if a teaching physician is present during the key portion of any service or procedure for which payment is sought. The teaching surgeon is responsible for the preoperative, operative, and post-operative care of the patient. The teaching surgeon may determine which post-operative visits are to be considered “key” and require his or her presence.

For Evaluation & Management Services: The teaching physician must be present during the portion of the service that determines the level of service billed regardless of the extent of the work performed by the resident.

Scenario 1:

• Teaching physician personally performs all the required elements of an E/M service without a resident.
• Where a resident has written notes, the teaching physician’s note may reference the resident’s note.
• Teaching physician must document that s/he performed the critical or key portions of the service and that s/he was directly involved in the management of the patient.

Acceptable Documentation for Scenario 1:

• Admitting note: “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
• Follow-up Visit: “Hospital Day #5. I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.”
• If there are no resident notes, the teaching physician must document as he/she would document an E/M service in a non-teaching setting.)

Scenario 2:

• 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.
• Teaching physician must document that he or she was present during the performance of the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient.
• Teaching physician’s note should reference the resident’s note.

Acceptable Documentation for Scenario 2:

• Initial or Follow-up Visit: “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.”
• Follow-up Visit: “I saw the patient with the resident and agree with the resident’s findings and plan.”

Scenario 3:

• Resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his/her service.
• Teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident.
• Teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient.
• Teaching physician’s note should reference the resident’s note.

Acceptable Documentation for Scenario 3:

• Initial Visit: “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• Initial or Follow-up Visit: “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
• Follow-up Visit: “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.
• Follow-up Visit: “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”

Following are examples of unacceptable documentation:

• “Agree with above.”, followed by legible countersignature of identity.
• “Rounded, Reviewed, Agree.”, followed by legible countersignature or identity.
• “Discussed with resident. Agree.”, followed by legible countersignature or identity.
• “Seen and agree.”, followed by legible countersignature or identity.
• “Patient seen and evaluated.”, followed by legible countersignature or identity.
• A legible countersignature or identity alone.
• Such documentation is not acceptable, because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.

Center for Medicare and Medicaid Services – www.cms.hhs.gov/manuals/14_car/3btocasp