Outpatient Facility Coding Alert - 2013 Issue 6
Reader Question: Don't Code Resident Services Off The Cuff
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Article Overview
This reader question addresses Medicare documentation for evaluation and management services involving residents. It focuses on the role of the attending physician’s review, confirmation, and linking statement, and it presents CMS examples of minimally acceptable attestation language. The article is relevant to coders, compliance staff, and providers who document teaching physician encounters.
Why This Topic Matters
Accurate physician documentation is essential for compliant E/M leveling when residents are involved. Understanding the documentation requirements helps reduce risk in Medicare billing and supports proper review of resident-generated history and exam information.
Article Sections
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Question
Introduces the documentation scenario involving a Medicare patient, a resident note, and the attending physician’s involvement in E/M service leveling.
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Answer
Summarizes the documentation expectations discussed in the article and notes the need for physician review and confirmation of resident-collected information.
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Examples of minimally acceptable documentation from CMS
Provides sample attestation language used to illustrate acceptable physician documentation for resident encounters under Medicare guidance.
What You Will Learn
- The documentation role of the attending physician in resident encounters
- Why review and confirmation of resident documentation matters
- What kinds of CMS attestation language are discussed for E/M services
- How this guidance relates to Medicare compliance and teaching physician documentation
Who Should Read This
- Medical coders
- Compliance professionals
- Physicians
- Residents
- Billing staff
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