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Linking to Resident Notes Billing E/M Services in
Teaching Settings
Clarification of Documentation Requirements for E/M
Services Billed by Teaching Physicians
CMS Section 15016; Effective 11/22/02
Print the “Linking to Resident Notes”
Quiz Before Viewing Presentation
Read Before Proceeding
Physicians and Staff may earn one compliance credit by
viewing this presentation, completing the assessment,
and faxing the assessment to 504-988-7777
This presentation may be viewed for compliance
credit only once in a fiscal year
(July 1 - June 30).
To check how many compliance credits you have and to see
which training sessions you have completed,
contact the University Privacy and Contracting Office at
504-988-7739
It is the policy of TUMG to provide healthcare
services that are in compliance with all state and
federal laws governing its operations and consistent
with the highest standards of business and
professional ethics. Education for all TUMG
physicians is an essential step in ensuring the
ongoing success of compliance efforts.
This education is Part 8 of a 9-part series on documenting and
selecting the level of service for outpatient visits.
All presentations are available on the Tulane University
Privacy and Contracting Office website:
http://tulane.edu/counsel/upco/billing-ed/
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Part 1: Overview of Basic
Principles
Part 2: Documenting a
History
Part 3: Documenting an
Exam
Part 4: Documenting
Medical Decision Making
Part 5: Documenting
Consults
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Part 6: Documenting PreOperative and
Confirmatory Consults
Part 7: Time-Based Codes
Part 8: Linking to
Resident Notes
Part 9: Modifiers 24 & 25
Focus of Presentation

To provide physicians and
staff with an overview of
the Medicare Teaching
Physician Rule as it
pertains to billing
documentation guidelines
for E/M services
Focus of Presentation
Discuss Medicare documentation
guidelines with regard to linking to
resident notes
 Provide samples of linking notes

Evaluation and Management
(E/M) Services

The revised language of the
Teaching Physician Rule
(November 2002) makes it clear
that for E/M services, teaching
physicians need not repeat
documentation already provided
by a resident.
E/M Guidelines are unchanged

For a given encounter, the selection of
the appropriate level of E/M service
should be determined according to the
code definitions in the American Medical
Association’s Current Procedural
Terminology (CPT) and any applicable
documentation guidelines.
This presentation does NOT apply to
Medicaid Billing
LA Medicaid only requires that
Teaching Physicians sign the
resident notes.
 No linking statement is required.

Documentation Guideline

A Teaching Physician (TP) must link to a
Resident note IF the TP will be using
documentation in the resident note to support
the level of service and reimbursement
Documentation Guideline

For example, if a Teaching Physician
relies on a resident to document any
portion of an E/M service (HX-EX-MDM) ,
then a linking statement is needed to
include the resident documentation in the
documentation for the visit.
Documentation Alert #1
If the Teaching Physician
does NOT link to the
resident’s documentation of
the E/M service, AND the TP
does not re-document the E/M
elements in his/her own note,
the history component of an
E/M service could not be
counted as support for a level
of service.
Not Linking To Residents Notes May Affect
The Level of Service and Reimbursement

Without a linking note,
a Teaching Physician
who relies on a resident
to document any
elements of an E/M
service would not be
able to bill for:
 A New Patient Visit
 An Initial Consult

New Patient and Initial
Consult E/M Services
requires all three E/M
Key Components be
documented:



History
Exam
Medical Decision
Making
Without linking to the resident documentation OR redocumenting the history in his/her own note, the Teaching
Physician could only bill for an Established Patient E/M service.
Medicare Documentation
Guidelines
Medicare Documentation

Refers to notes recorded in the medical
record by a resident, and/or teaching
physician or others

May be dictated and typed, handwritten
or computer-generated

Must be dated and include a legible
signature or identity
Medicare Documentation

Must identify, at a minimum

the service furnished

participation of the teaching
physician in providing the service

whether the teaching physician
was physically present
Medicare’s General
Instructions
 When
assigning codes to
services billed by teaching
physicians, reviewers will
combine the documentation of
both the resident and the
teaching physician – provided
the TP linked to the resident
documentation.
Medicare’s General Instructions Regarding
Teaching Physician Presence

For OUTPATIENT and INPATIENT E/M
SERVICES, the resident cannot attest to a
Teaching Physician’s presence.
 The
TP must document his/her presence and
participation in the plan of care.
Medicare’s General Instructions when using
both Resident and Teaching Physician
notes to support a level of service
On medical review, the combined entries
into the medical record by the teaching
physician and the resident constitute the
documentation for the service and
together must support the medical
necessity.
 NOTE: The notes cannot be combined
without a linking statement.

For purposes of payment, a
Teaching Physician
must document:

That he/she performed the E/M
service or was physically present
during the key or critical portions of
the service when performed by the
resident; AND

His/Her participation in the
management of the patient
The Teaching Physician Rule identifies three
Scenarios for E/M services performed in a
teaching setting:
Teaching Physician
Resident Scenarios
Scenario 2Scenario I –
No resident’s note
Resident’s note E/M elements
Documented in
presence of, or
jointly with
Teaching Physician
Scenario 3Resident’s note –
E/M elements
documented
in absence of TP
Medicare’s Minimally Acceptable
Documentation must support the
necessity of the Teaching Physician’s
 Presence
 Participation
 Plan of Care
Scenario I - Teaching Physician
without resident note
 Teaching
Physician personally
performs all required elements
of an E/M service w/o resident.
Scenario 1 – Documentation without
a resident note

The teaching physician must document
as he or she would document an E/M
service in a non-teaching setting.

Level of Service and reimbursement
would be determined by the physician’s
note alone.
Scenario 2: Teaching Physician and
Resident see patient together

The resident performs the elements
required for an E/M service in the
presence of, or jointly with, the
teaching physician, and the resident
documents the service.

The Teaching Physician links to the
Resident’s documentation. The
combined notes would support the
level of service and the reimbursement.
Scenario 2 –
What the Teaching Physician Must Document

Teaching physician must
document that he/she was
present during the
performance of the critical
or key portions of the
service and that he/she was
directly involved in the
management of the patient.
Scenario 2 –
What the Documentation Must Support

For payment, the composite of the teaching
physician’s entry and the resident’s entry
together must support:
the medical necessity of the billed service
and
 the level of the service billed by the teaching
physician.

Scenario 2 - Linking Statements: Minimum
documentation examples.

Initial or follow-up
visit: “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.”

Follow-up Visits:
“I saw the patient with
the resident and agree
with the resident’s
findings and plan.”
Scenario 3 –Teaching Physician and Resident
see Patient At Different Times

In this practice scenario, the resident
performs and documents some or all of the
required E/M elements without the
Teaching Physician.
The Teaching Physician independently
performs the critical or key portion(s) of
the E/M service with or without the resident.
Scenario 3 – Teaching Physician
Linking/Documentation Requirements

In this practice scenario, the Teaching
Physician’s documentation, in addition to
linking to resident’s note, must reflect the
following:
 that
he/she personally saw the patient,
 personally performed key or critical portions
of the E/M service, and
 participated in the management of the
patient.

Teaching physician’s note should link to the
resident’s note when using the resident’s
documentation for billing the E/M service.
Resident
Note
TP
Note
The Teaching Physician must write/dictate the
linking statements that allow his/her note and
the resident note to be combined as support
for the level of service and reimbursement
Scenario 3 Minimum documentation examples.

Initial or follow-up visit: “I saw
and evaluated the patient.
Discussed with resident and agree
with resident’s findings and plan as
documented in the resident’s note.”

Initial visit: “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.”

Follow-up visit: “See
resident’s note for details.
I saw and evaluated the
patient and agree with
the resident’s findings
and plan as written.”
Scenario 3 – Documentation Alert!

Documentation that
does not clearly
establish that the
“teaching physician
was present,
evaluated the patient,
and/or had any
involvement in the
plan of care” is
unacceptable.
Examples of Unacceptable
Documentation
“Agree with above”
“Rounded, reviewed, agreed”
“Discussed with resident”
Teaching physician notes must be
linked to resident notes

NOTE: even if those
notes were followed by a
legible Teaching
Physician signature, they
would not meet minimum
documentation
guidelines.
What is missing?
 None
of the examples establish
whether the physician was either:
 Physically
present when resident
performed some or all E/M elements
OR
 Whether the resident performed
some or all E/M elements in the
absence of the TP .
Medical Student
Documentation of E/M
Services
To refer to student documentation, the
E/M services “must be performed in the
physical presence of a teaching physician
or physical presence of a resident.”
CMS, transmittal 1780, page 15-12, 11/2002
Documentation Alert!

For billing purposes, the Teaching
Physician may only refer to medical
student documentation of the
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
ROS (Review of Systems)
and/or PFSH (Past Family/Social History).
Documentation Alert!

No Medical Student documentation of a
Chief Complaint,
 History of Present Illness,
 Exam, and/ or
 Medical Decision-Making

can be used to support a level of service,
regardless of whether the documentation
was done under the supervision of a
resident or Teaching Physician.
Documentation Alert!
“If a medical student documents E/M
services, the teaching physician must
verify and re-document the history of
present illness as well as perform and
re-document the physical exam and
medical decision making activities of
the service.”
CMS15016, page 15-12, 11/2002
Summary of Teaching Physician
Documentation Requirements
No resident note
 Teaching
Physician
documents as he/she would
document any E/M service –
level of service and
reimbursement determined
solely by TP’s note.
TP and Resident see patiently jointly:

TP must establish/document his/her:
 Presence
 Participation
 Plan

of Care
TP must link to resident’s note
TP and Resident see patient at
different times:

TP must establish:




Presence
Participation –Must state he/she personally
performed the critical elements of the exam
Participation in the plan of care
TP must link to resident’s note
Medical Student Documentation

Medical Student Documentation that may
be used for billing purposes under the
teaching physician rule is limited to:



Review of Systems
Past Family/Social History AND
The documentation must be done in the
presence of a TP or resident
Medicare Payment Guidelines

For payment, the composite of the teaching
physician’s entry and the resident’s entry
together must support the medical necessity
of the billed service and the level of the
service billed by the teaching physician.
Bottom Line: If your resident’s note has
documentation that you intend to use as
support for the level of service you select,
you must link to that resident note.
Did you review your resident’s notes?
The Teaching Physician
Guidelines stress that
physicians must review
resident notes.
Linking without reading the
resident note may result
in a documentation –
level of service mismatch.
TUMG physicians are
responsible for selecting
the level for their
outpatient services.
GO TO THE SOURCE

Transmittal 1780, Supervising
Physicians in Teaching Settings, can
be found on the CMS (Center for
Medicare and Medicaid Services)
website:

http://www.med.ufl.edu/complian/Q&a/CMS_
Transmittal_R1780B3.pdf
A Final Note…
The TUMG Compliance Staff
can assist with developing
documentation templates
and linking statements.
Assistance is Just an Email
Away…
Know who to contact:
 TUMG
Business Services
 Compliance
Reporting Hotline:
504-988-5142
Good Things Happen When You Know
the Rules
The TUMG Compliance Staff serves as a resource
to Tulane Physicians for continuous education
and improvement that will encourage and
support consistent compliance with key payor
requirements.
End of Presentation
To Earn One Compliance Credit:
Complete and Sign the “Teaching Physician
E/M Documentation Guidelines” Quiz
Fax to: 504-988-7777