decisionhealth Newsletters, Answer Books - 2011 Issue 7 (July)
Answer_Book / Teaching_Physicians_Residents_And_Interns / Documentation requirements for EM services
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Article Overview
This premium guidance reviews documentation requirements for teaching physician involvement in evaluation and management services, with emphasis on how resident, intern, and student notes support the medical record. It is intended for coders, compliance staff, physicians, and clinical documentation teams who need to understand the documentation framework and examples discussed by CMS-based guidance.
Why This Topic Matters
Teaching physician documentation affects whether E/M services are supportable for payment and whether the combined medical record shows medical necessity, presence, and participation appropriately.
Article Sections
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Documentation requirements for E/M services
Overview of the documentation expectations for teaching physicians and the relationship between physician and resident notes.
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Scenario 1
A documentation scenario where the teaching physician personally performs the service and how that affects the note structure.
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Scenario 2
A scenario involving resident-performed service elements in the presence of the teaching physician and the associated documentation relationship.
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Scenario 3
A scenario where the resident documents part of the service and the teaching physician independently documents key portions.
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Scenario 4
A delayed teaching physician encounter after the resident has already documented the admission or visit, with emphasis on record coordination.
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Unacceptable documentation examples
Examples of documentation patterns that do not sufficiently establish the teaching physician’s involvement.
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Students and documentation
Guidance on the limited role of student documentation in the medical record and what the teaching physician may reference.
What You Will Learn
- How teaching physician documentation is expected to support E/M service reporting
- How resident documentation interacts with the teaching physician note
- What types of documentation examples are considered acceptable or unacceptable
- How student documentation is limited within teaching physician records
- How CMS-based guidance frames presence, participation, and record verification
Who Should Read This
- Medical coders
- Compliance professionals
- Physicians
- Residents
- Medical documentation staff
- Billing staff
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