We have received an increased number of questions regarding required medical record documentation to support compliance with the Medicare teaching physician rules for E/M services.  We have highlighted some of the key rules and criteria below.  In all cases, the teaching physician documentation should be adequate to independently support that he/she performed the service or was physically present during the key or critical portions of the service when performed by a resident and that he/she was involved and participated in the management of the patient.

1. GME program granted primary care exception

1. 1. Applies to the following CPT codes only: 99201, 99202, 99203, 99211, 99212, 99213, G0402, G0438, G0439
   2. Residents who have completed at least 6 months of a GME approved residency program may provide billable patient care services (limited to the applicable CPT codes) in the absence of a teaching physician.
   3. The teaching physician may not supervise more than 4 residents at any given time and must be immediately available.
   4. The teaching physician must review the care provided by the resident during or immediately after each visit including a review of the patient’s medical history, resident’s findings on physical examination, the patient’s diagnosis and treatment plan.
   5. The teaching physician must document the extent of his/her own participation in the review and direction of the services furnished to each patient.
   6. Example of acceptable teaching physician documentation:
      1. I reviewed the history and physical exam documentation by the resident and agree with the findings.  I discussed the case with the resident and agree with the diagnosis, management and plan of care documented by the resident.
   7. Example of unacceptable teaching physician documentation:
      1. Agree with above
      2. Countersignature alone
2. E/M Services
   1. The teaching physician is required to document that they performed the service or were 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.
   2. 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.
   3. Examples of acceptable teaching physician documentation include:
      1. I performed a history and physical examination of the patient and discussed his management with the resident.  I reviewed the resident’s note and agree with the documented findings and plan of care.
      2. I was present with the resident during the history and exam.  I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.
   4. Examples of unacceptable documentation include:
      1. Agree with above
      2. Discussed with resident, agree
      3. Countersignature alone

Additional information regarding the Medicare teaching physician rules can be found in Chapter 12 of the Medicare Claims Processing Manual as well as the CMS Medicare Learning Network resource Guidelines for Teaching Physicians, Interns, and Residents:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf

We recommend conducting periodic audits of your teaching physician documentation to confirm compliance with the Medicare guidelines.