E/M Coding Alert - 2017 Issue 3
Reader Question: Look for the Link Before Counting Resident Documentation in Your Code Selection
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Article Overview
This reader question and answer explains a Medicare documentation issue involving resident notes, attending physician attestation, and evaluation and management (E/M) service leveling. It is intended for coders, billers, auditors, and clinicians who work with Medicare documentation requirements and need to understand the general type of supporting documentation discussed in CMS guidance.
Why This Topic Matters
Documentation alignment between residents and attending physicians can affect whether E/M service support is considered valid for Medicare claims review.
Article Sections
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Question
The reader describes a documentation workflow involving resident and attending physician notes in a Medicare encounter and asks how the chart should be used for E/M leveling when documentation appears at different times.
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Answer
The response summarizes the need for physician linkage and confirmation in the record and refers to CMS guidance on acceptable documentation support for resident-based encounters.
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Examples of minimally acceptable documentation from CMS
The article provides illustrative attestation language examples drawn from CMS guidance to show the general form of documentation discussed in the answer.
What You Will Learn
- How the article frames Medicare E/M documentation involving residents and attending physicians
- Why documentation linkage is relevant to chart review
- What type of CMS guidance is referenced for resident-based encounter documentation
- How the article presents examples of acceptable attestation language
Who Should Read This
- Medical coders
- Billing specialists
- Compliance auditors
- Physicians
- Residents
- Revenue cycle staff
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