Documentation of Teaching Physician Services

During a recent CERT review, the CERT contractor assessed errors on a teaching physician's claim for inpatient hospital visits performed by a resident because the teaching physician did not document his active role during the inpatient hospital visits.

Per the Centers for Medicare & Medicaid Services (CMS) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 100.1.1, where a resident has written notes, the teaching physician's note may reference the resident's note. The teaching physician must document that he/she performed the critical or key portion(s) of the service, and that he/she was directly involved in the management of the patient. For payment, the composite of the teaching physician's entry and the resident's entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician.

View the Publication 100-04, Chapter 12Adobe Portable Document format, including other CMS Teaching Physicians Services instructions.

Page Last Updated: Wednesday, 05-Oct-2011 13:29:26 CDT