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Teaching Physician Documentation

Teaching Physician Documentation May 7, 2019

The CMS recently released a Medlearn Matters article to clarify documentation changes for teaching physicians (TP) providing evaluation and management (E/M) services. The policy changes were effective on January 1, 2019. The Medicare Claims Processing Manual no longer requires the TP to personally document the extent of their participation in E/M services provided by a resident. Documentation of the TP’s participation may be recorded by the TP, resident or nurse. However, the Medlearn article emphasizes the medical record must demonstrate:

  • The TP performed the service or was physically present during the key or critical portions of the service when performed by the resident;
  • The participation of the TP in the management of the patient; AND
  • The extent of the TP’s participation in the review and direction of services furnished to the patient.

If your organization provides and bills for TP services, we recommend conducting a proactive audit to ensure the documentation requirements are met and your staff understands the recent policy changes. HBE has extensive experience in auditing and providing training for TP services to promote compliance and are available to provide assistance with the services.

The Medlearn Matters article can be found at:

The Medicare Claims Processing Manual, Chapter 12, Section 100.1.1, provides the current policy language and requirements and can be accessed here:

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