Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.

Question: How should my residents and I document examinations they perform?

Answer: Residents are supported in part by graduate medical education funds paid to hospitals by the Centers for Medicare & Medicaid Services (CMS). Teaching physicians (TPs) who work with residents should understand the care provided by residents has essentially been paid for by CMS. Only the care that is personally provided by TPs is payable. TPs should see the patient, confirm the history and examination, and actively participate in the medical decision making.

The good news is TPs do not have to write a separate note. TPs can review, confirm, and correct the resident note and may choose to expand on the medical decision making and treatment provided. TPs may see the patient concomitantly with the resident or separately. When incorporating the resident note, TPs must include an attestation that reflects the care they delivered and meets CMS requirements, such as, “I personally evaluated and examined the patient and discussed the care with the resident. I agree with the resident’s written findings and plan, except as noted.”

If residents perform a procedure that takes more than five minutes, TPs must document that they were present for the “key or critical” portion of the procedure. See the ACEP Teaching Physician for further details.

Brought to you by the ACEP Coding and Nomenclature Committee.

Dr. Lemanski is associate professor of emergency medicine at Baystate Medical Center/Tufts University School of Medicine in Springfield, Massachusetts.