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Teaching Physican Guidelines

Patricia Posted Thu 02nd of May, 2013 17:11:19 PM

If no linking statement by the attending is present which part of the resident's note may be uses in leveling an E&M Service.

SuperCoder Answered Mon 06th of May, 2013 20:57:34 PM

With no linking statement of any kind I’d say none of it, not even ROS and PFSH. There has to be a linking statement along the lines of those pasted below from the transmittal.

Following are examples of minimally acceptable documentation for each of these scenarios:
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 #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
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.”
(NOTE: In this scenario 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:
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 resident’s note.”
Follow-up Visit: “I saw the patient with the resident and agree with the resident’s findings and plan.”
Scenarios 3 and 4:
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.”

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