Outpatient Facility Coding Alert - 2013 Issue 19
Reader Question: Residents' Notes Require Linking Statement
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Article Overview
This reader question addresses Medicare documentation standards related to resident notes, attending physician review, and the linking statement needed to support evaluation and management service leveling. It is aimed at coders, compliance staff, and clinical documentation teams who work with teaching physician records and CMS guidance. The article includes example attestation language and clarifies the role of resident-collected history elements in the documentation process.
Why This Topic Matters
Accurate physician attestation is important for compliant E/M reporting in teaching settings and for understanding what documentation can support the billed service.
Article Sections
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Question
Presents the reader’s documentation question about resident notes and E/M service leveling under Medicare rules.
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Answer
Summarizes the documentation requirement being discussed and introduces CMS example attestation language.
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Following are examples of minimally acceptable documentation from CMS
Lists sample attending physician statements provided as guidance for documentation in teaching physician settings.
What You Will Learn
- How Medicare teaching-physician documentation is discussed in relation to resident notes
- Why an attending physician linking statement matters for E/M documentation
- What broad kinds of attestation language CMS has shown as acceptable examples
- How resident-collected history elements are treated in the documentation review process
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Clinical documentation improvement staff
- Physicians in teaching settings
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