“I have read and concur” is not sufficient documentation of teaching physician presence when a resident has examined a Medicare patient.
Use of generic attestations of participation in the key elements by the teaching physician are not acceptable for visit E&M services, however they are acceptable when used in radiology, diagnostic test reports and routine anesthesia reports. Simple attestations must be patient specific.
As of 1/1/2019, for new and established E/M visits in the office and outpatient setting, providers may refer to previously documented information on the patient’s chief complaint and history, entered in the medical record by ancillary staff, by the patient or by residents in a teaching setting.
There is a clear expectation that complaint and history information, particularly history of the present illness (HPI), be carefully reviewed and noted by the performing provider. In many circumstances, clinical skill is needed to determine the scope and course of questioning relative to this process; the provider remains obligated to assess previously recorded information and to expand upon it as medically necessary.
Previously recorded information on defined E/M elements (history, examination and medical decision making) may also be referred to in documentation for a visit, when there is clear evidence that the provider has reviewed this earlier information and either updated it as appropriate to the clinical scenario. For example: “12/15/2018: Since last seen on 11/10/2018, no significant interval history. Physical examination remains unchanged except for drop in BP from 160/90 to current 140/80 on current Losartan regime. Will maintain all current meds and schedule return visit in early February 2019.”
Templates:
According to CMS, any format or method used by the physician for documenting the encounter is acceptable as long as the supportive information pertaining to a level of service can be understood from a review of the medical record. It is acceptable to write “negative” or place a check mark in a designated column for an element with normal findings. Comments on abnormal, unexpected findings and pertinent information must be recorded. A check off list for ROS (Review Of Systems) is acceptable.
Using pre-populated templates with exam and plan are discouraged. If billing for a new comprehensive exam, a pre-populated template cannot be used. If, however, the comprehensive exam was done two months ago and repeated today in the same level of detail and nothing has changed, then the provider can refer back to the prior. But, if this is a new comprehensive visit, it would have to be fully documented.
A scribe records word for word what a provider is saying. In documenting any patient encounter, the scribe neither acts independently nor functions as a clinician, but simply records the provider’s dictated notes during the visit. An attestation needs to be included by the provider. For example: “The documentation recorded by the scribe accurately reflects the service I personally performed and the decisions made by me.”
Addenda to documentation are acceptable if added for legitimate medical reasons. Retrospective documentation, i.e., after a claim is filed, performed primarily for compliance with documentation requirements is discouraged.
