decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Academic Medical Centers / 3 Ways to Improve Compliance with Teaching Doc Rules
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Article Overview
This article explains documentation compliance considerations in academic medical center and teaching physician environments. It focuses on how different participants in patient care documentation are treated, what kinds of physician involvement must be documented, and how Medicare guidance frames record support for evaluation and management services. The material is aimed at compliance, coding, and documentation professionals who need to understand teaching physician record requirements at a high level.
Why This Topic Matters
Teaching physician documentation affects audit support, claim integrity, and compliance in academic settings. Understanding the scope of required documentation helps organizations reduce risk when residents, students, and scribes are involved in care.
Article Sections
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Documentation roles for students, residents, and scribes
Discusses how documentation responsibilities differ among medical students, residents, attending physicians, and scribes in a teaching setting. The section addresses general documentation participation and oversight expectations.
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Scenario 1
Covers a teaching physician scenario involving service performance without a resident note present. The section outlines the general documentation relationship between teaching physician and resident records and references Medicare guidance.
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Scenario 2
Covers a scenario where the resident performs service elements in the teaching physician’s presence or jointly with the physician. The section focuses on the relationship between the teaching physician record and the resident record for support of the billed service.
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Scenario 3
Covers a scenario where the resident and teaching physician document service involvement at different times. The section discusses how the teaching physician record and resident record work together in the teaching setting.
What You Will Learn
- How documentation responsibilities are divided among members of the teaching care team
- How teaching physician involvement is generally reflected in the medical record
- How Medicare guidance is presented in the context of teaching physician documentation
- How compliance concerns arise when multiple clinicians contribute to the record
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Health information management staff
- Academic medical center billing staff
- Physician documentation reviewers
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