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Evaluation and Management Documentation Guidelines for Teaching Physicians


For a given encounter, the selection of the appropriate level of E/M services is determined according to the code of definitions in CPT books and any applicable documentation guidelines. CPT books are available from the American Medical Association. When a Teaching Physician bills for E/M services, he or she must personally document at least the following:

• That he or she performed the service or was physically present during the critical or key portions of the service furnished by the resident; and

• His or her participation in the management of the patient.

On medical review, the combined entries into the medical record by the teaching physician and resident constitute the documentation for the service and together must support the medical necessity of the service. Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the    presence and participation of the teaching physician.

Evaluation and Management Documentation Provided by Students

Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements (other than the review of systems [ROS] and/or past, family, and/or social history [PFSH], which are taken as part of an E/M service and are not separately billable). You, the student, may document services in the medical record; however, the teaching physician may only refer to your documentation of an E/M service that is related to the ROS and/or PFSH.

The teaching physician may not refer to your documentation of physical examination findings or  medical decision making in his or her personal note. If you document E/M services, the teaching physician must verify and redocument the history of present illness and perform and redocument the physical examination and medical decision making activities of the service.

Exception for Evaluation and Management Services Furnished in Certain Primary Care Centers....Read more

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