Web-based Teaching Physician Course

CMS Compliance Rules For Supervising Physicians in Teaching Settings

Welcome to the Compliance Educational program for URMC providers. Due to the complexity of Medicare documentation guidelines, interpretation of regulations by experts may vary at times. Before beginning this online training program, please review the six areas below where the URMC policy or interpretation varies from that of the Yale/PricewaterhouseCoopers program.

Clarification of URMC Policy/Interpretation

Patients admitted to Highland and Strong Memorial Hospitals must be seen daily.

This course and its quizzes accurately stress the fact that CMS does not require "teaching physicians" to see every Medicare patient. However, New York State law requires surgeons see post-operative inpatients daily and the By-laws of both hospitals require that inpatients receiving an acute level of care be seen by an attending physician every day.

When taking this course and coding examples, we highly recommend you concentrate on the 1995 guidelines for physical examinations.

Under the current guidance from CMS, providers may use either the 1995 or 1997 guidelines. Most physicians find the 1997 guidelines onerous and elect to follow the 1995 guidelines.

Under the 1995 Guidelines, 2-7 exam elements are required for BOTH the Expanded Problem Focused Exam and the Detailed Exam.

The 1995 CMS guidelines state that an Expanded Problem Focused Exam has 2-7 exam elements (body areas and/or organ systems) and a Detailed Exam has 2-7 "detailed" exam elements. The number of exam elements listed in this course is an interpretation only a few carriers have accepted. The difference between the two levels is in the content specified. For example, if a patient presented with a cardiovascular problem, the following examples could document the exams:

Expanded Problem Focused

• Eyes normal
• ENT normal
• Lungs clear
• Heart RRR

Detailed

• Eyes normal
• ENT normal
• Lungs clear
• Heart – RRR, no carotid bruits, peripheral pulses WNL

The same four areas were examined in the above examples, but the detailed exam includes specific detail for the cardiovascular exam—the area of the patient's presenting problem.

Time-based codes require documentation of the total time of an encounter and a description of the service.

In the "Definition of Key Portions of Service" section of the course, there is an erroneous statement that the medical record should reflect the time spent in counseling and/or coordination of care. While it is good practice to document this time, it does not replace the requirement to document the total patient care time.

When working with residents, two of the components that must be a part of the physician's note are an HPI statement and either a clear statement of presence during the resident's exam or the key findings of the physician's own exam.

Some examples infer rather than clearly state these two important components. AAMC provides the following examples of wording that meets CMS requirements of patient specific comments for each key element:

Hx:

“Resident's history as documented above reviewed, patient interviewed and examined. It is noted that (state history of present illness and add anything else remarkable to the ROS or PFSH)...”

Exam (3 examples, depending on clinical encounter):

• “On exam I find...”
  
  OR
• “My exam confirms (revises) all the resident's findings of note. These are...”
  
  OR
• “I was present during the resident's exam of note. The findings are…”

Decision Making

• Usually includes comments on diagnostic studies.
  • “Lab tests (specify key diagnostic and other tests performed) show …”, “indicating…”
  • “Radiology studies show …“
• Teaching physician comments on differential diagnoses, 2 examples.
  • “I confirm (revise) the resident's assessment as …, and diagnosis of …”
  • “I agree (revise) with the resident's plan of care as follows: …”
    
    OR
  • “Upon review, I agree (revise) with resident's assessment and plan of care. Differential dx is …”, “Plan is to …”, “See resident's note of xx/xx/xx for complete details of this service.”

Do NOT use the terms "unremarkable" (as seen in Examples 2A and 2B) or "non-contributory" in documenting the PFSH and review of systems.

Our Medicare Administration provided guidance that these two terms are not acceptable. They state: "In order to confirm whether the service was done or not, the physician should document what they did do." CMS guidelines do indicate that the terms "negative" or "all other systems negative" are acceptable.

Accessing the Web-based Training Course

When you access the course (below), we recommend you bookmark the Login page. The bookmark will read "Login". You can then access the course from your bookmark or from this page.

Questions

Should you have any questions about this course or your documentation practices, please contact your department's Compliance Liaison or call the Compliance Office at (585) 275-1609.

Start the web-based training course