Appropriate Documentation for Services of Supervising Physicians in Teaching Settings
Insufficient documentation by providers acting as supervising physicians in a teaching setting could cause Medicare to deny your services.
Documentation may be dictated and transcribed, hand-written, typed or computer-generated.
Documentation must be dated and include a legible signature.
The attending physician who bills Medicare must personally document:
- The services furnished
- His/her participation in providing the service and
- Whether he/she were physically present
The billing provider cannot simply co-sign the resident's documentation. He/she must indicate whether they were physically present during the Resident's services or separately performed key portions of the E/M service as required in the Medicare Policy PHYS-024.
You can view and download a copy of Medicare policy PHYS-024 at the following Wisconsin Physicians Service (WPS) Medicare address: http://www.wpsmedicare.com/part_b/policy/policy_active.shtml
Additional resources:
Guidelines for Teaching Physicians, Interns, and Residents at the following Centers for Medicare & Medicaid Services (CMS) address:
http://www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf
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Page Last Updated: Thursday, 18-Mar-2010 05:55:28 CDT
