What are the documentation requirements for hospital visits in a teaching facility?

Answer: Physician services to patients in a teaching facility are covered under Part B. Documentation can be typed, dictated, handwritten or computer generated. Documentation must include the patient’s name, date of service, and legible signature or identity of the person entering the information and performing the service. Documentation must also identify, at a minimum:

  • The service furnished
  • The participation of the teaching physician in providing the service
  • Whether the teaching physician was physically present. The teaching physician must personally document:
    • He/she performed the service or was physically present during the key or critical portions of the service when performed by a resident
    • His/her participation, as a teaching physician, in the management of the patient

Resource: CMS guidance regarding teaching physicians and documentation is available in the CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, Section 100 (PDF, 1.4 MB).

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