Outpatient Facility Coding Alert - 2015 Issue 4
Reader Question: Make Sure The Link Is Strong Before Counting Resident Documentation
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Article Overview
This reader question explains Medicare documentation expectations for E/M leveling when a resident participates in the visit. It focuses on the need for physician linkage and review of resident-entered history elements, and it cites CMS examples of acceptable attestation language. The article is relevant to coders, compliance staff, billing personnel, and physicians working with teaching settings and Medicare claims.
Why This Topic Matters
Accurate physician attestation is essential in teaching environments because it affects whether resident documentation can support E/M billing under Medicare rules. Understanding the documentation relationship helps reduce compliance risk and claim denials.
What You Will Learn
- The role of physician attestation when a resident documents part of a Medicare encounter
- Which categories of resident documentation require physician review and confirmation
- How CMS has illustrated acceptable linkage language in teaching-physician documentation
- Why resident documentation practices matter for E/M service leveling in Medicare settings
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Billing staff
- Physicians
- Residents
- Practice managers
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