tci ED Coding & Reimbursement Alert - 2002 Issue 2

Reader Question: Residents in the ED

Question: What are the documentation requirements when an attending physician supervises a resident in a teaching setting? For instance, does the history of present illness (HPI) or separately billable procedures need to be documented by the teaching physician for a claim to be submitted?Texas Subscriber  Answer: Because the Office of the Inspector General (OIG) has stated it will closely watch areas like this for fraud and abuse, it is wise for supervising ED physicians to perform and document their own service in addition to the care provided by the resident. In other words, if a resident provides...

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