tci General Surgery Coding Alert - 2003 Issue 3

Documentation Requirements Ease for Teaching Physicians

By Eric Sandham, CPC Under new Medicare rules, teaching physicians will find it easier to document services provided with residents and medical students. CMS will no longer require physicians to repeat services already provided by residents and instead will focus on the key elements of care.No More History Repeating Prior to the new guidelines (effective Nov. 22, 2002), Medicare required attending physicians to document the key elements of history, exam and medical decision-making (MDM) separately, in addition to noting their personal presence (or independent verification) and discussion of a resident's findings. The implication was that the teaching physician...

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