The Physicians Regulatory Issues Team (PRIT) is a group of subject matter experts with the Center for Medicare and Medicaid Services (CMS) who work to reduce the regulatory burden on physicians who participate with the Medicare Program. PRIT’s mission can be described by a quote from the Director, William Rogers, M.D., of PRIT posted on their website.
“It is my goal to simplify the lives of physicians by the elimination of unnecessary regulation, and help make Medicare participation a pleasure rather then a burden.”
As part of attaining that goal, PRIT has modified the teaching physician documentation requirements for physicians using an electronic medical record. The new guidance states:
In the context of an electronic medical record, the term ‘macro’ means a command in a computer or dictation application that automatically generates predetermined text that is not edited by the user. When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation if the teaching physician adds it personally in a secured (password protected) system. In addition to the teaching physician’s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. It is insufficient documentation if both the resident and the teaching physician use macros only.
The new guidance demonstrates that CMS is taking electronic medical record systems and functionality into consideration when drafting policies.
- In order to bill for services furnished in teaching settings, the services must be: Personally furnished by a physician who is not a resident;
or
- Furnished by a resident where a teaching physician was physically present during the critical or key portions of the service.
For purposes of payment, Evaluation and Management (E/M) services billed by teaching physicians require that they personally document at least the following:
- That the teaching phyisican was physically present during the key or critical portions of the service when performed by the resident; and
- The participation of the teaching physician in the management of the patient.
Examples of Acceptable Teaching Physician Documentation
“I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
“I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
“See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
“I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”
Examples of Unacceptable Teaching Physician Documentation
“Agree with above.”, followed by legible countersignature or identity;
“Rounded, Reviewed, Agree.”, followed by legible countersignature or identity;
“Discussed with resident. Agree.”, followed by legible countersignature or identity;
“Seen and agree.”, followed by legible countersignature or identity;
“Patient seen and evaluated.”, followed by legible countersignature or identity; and a legible countersignature or identity alone.
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.
The “unacceptable” documentation examples do not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.
All documentation systems should be able to provide an audit trail of who provided each component of the medical record documentation, the discipline of who provided the documentation and the date the documentation was created or revised.