tci ED Coding & Reimbursement Alert - 1999 Issue 5

Reader Question: Documentation for Teaching Physicians

Question: When seeing a Medicare patient, does the history of present illness (HPI) have to be documented by the attending physician when that doctor is supervising a resident in a teaching setting? And, do all separately billable procedures need to be documented by the teaching physician supervising the resident?ECA SubscriberAnswer: At issue in these questions is how complete the documentation by an attending physician should be, especially concerning a Medicare patient. For example, is it enough for the attending physician to simply write that he or she has reviewed the residents HPI and agrees with it? When all...

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