Teaching physician documentation guidelines for anesthesia services

There are specific guidelines in billing service provided by physicians in a teaching setting. The guidelines for anesthesia services, flat fees (lines, blocks and other ancillary services) and evaluation and management services are different. This document will clearly outline each scenario and what documentation is required in order to bill for services. Failure to provide the proper documentation for each scenario could make your teaching physician services non-billable.

Regarding documentation for anesthesia services, the teaching physician must document his/her presence with the patient during the key portions of the procedure, which include induction and emergence when applicable. The physician must also document his/her immediate availability during the entire procedure.

Example Attestation: I was present for induction, emergence and key portions of the anesthesia services and immediately available throughout the duration of the service.

Flat Fees (line placements, blocks, intubations, etc.)
Physicians must document that they were physically present during the procedure. This is a requirement for all procedures of 5 minutes or less.  The vast majority of flat fee services fall into this category, and physicians can still document their physical presence during the entire procedure if it goes over five minutes.

Example Attestation: I was physically present for the entire procedure.

Evaluation and Management Services

There are several scenarios for E&M services. First, 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. In this case, the teaching physician must document that he/she was present during the performance of the critical or key portion(s) of the service and that he/she was directly involved in the management of the patient. As well, the teaching physician’s note should reference the resident’s note. For payment, the composite of the teaching physician’s entry and the resident’s entry together must support the medical necessity and the level of the service billed by the teaching physician.

Example Attestation I personally saw the patient with the resident and agree with his/her assessment, findings and plan.

It should also be noted that the level of service is assigned based on the combined documentation of both providers. Second, the resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his/her service. The teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident. In this instance, the teaching physician must document that he/she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The teaching physician’s note should reference the resident’s note. 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.

Example Attestation: I personally saw and examined the patient without the resident and agree with his/her assessment, findings and plan with the exception the patient is running a low grade fever at the time of my visit.  Will order a CBC and chest x-ray.

It should also be noted that the level of service is assigned based on the combined documentation of both providers.

In closing, the documentation for teaching physician services varies depending on the type of service provided. Failure to accurately document your participation in each unique scenario could result in a non-billable service.

Pamela Linton, CPC, CANPC is a Corporate Coding Quality Specialist with Zotec Partners.

© Copyright ASC COMMUNICATIONS 2019. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.

 

Top 40 Articles from the Past 6 Months