tci ED Coding & Reimbursement Alert - 2003 Issue 2

Reader Question: Documentation Scenarios from Transmittal 1780

Below are the three scenarios that CMS offers for teacher physician guidelines verbatim, as referenced in the article on page 4.#1: The teaching physician personally performs all the required elements of an E/M service without a resident. In this scenario, the resident may or may not have performed the E/M service. In the absence of a note by a resident, the teaching physician must document as he or she would document an E/M service in a non-teaching setting. Where a resident has written notes, the teaching physician's note may reference the resident's note. The teaching physician must document...

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