Teaching Physician Documentation in the Era of Electronic Medical Records (EMR)

Compliance with the Medicare documentation rules in the era of Electronic Medical Records (EMR) is a frequently questioned issue. Palmetto GBA provides specific guidance regarding documentation; however, this documentation may be interpreted differently when reviewed independently by a CERT contractor, a qualified independent contractor (QIC), a Recovery Audit Contractor (RAC) or an Administrative Law Judge.

The Centers for Medicare & Medicaid Services (CMS) provides guidance regarding documentation by teaching physicians involved in patient care with residents in the CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, Section 100. The necessary elements are discussed in light of multiple scenarios, including evaluation and management (E/M) services, surgical procedures, psychiatry, time-based codes, anesthesia, radiology and complex high-risk procedures.

The determining factor in any review of medical records is the content of what is documented in the medical record entry and not how it is documented. EMR can be used by both residents and teaching physicians to make entries. Use of a limited number of macros is not sufficient to encompass all possible scenarios. For example, when documenting an E/M service, the teaching physician must always personally document his or her physical presence during the key and critical portions of the service when performed by a resident as well as his or her participation in the patient’s management. This requires an entry by the teaching physician into the EMR to support the medical necessity of the service.

The key or critical portion of the service will vary from one encounter to the next, therefore the teaching physician’s note must specifically identify the key/critical portion of the service so the reviewer will know what part of the service the teaching physician considered to be critical. Similarly, only the teaching physician can document his or her personal participation in the patient’s management. The resident’s documentation of the teaching physician’s personal participation is not sufficient.

In summary, the same documentation requirements outlined in the CMS manual referenced in this article apply to all methods of medical record entry, including handwritten, dictated and typed, and electronic.

• CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, Section 100 (PDF, 1.13 MB)