Teaching Physician Attestations – E/M

Teaching physicians certify appropriate supervision of resident services by appending an attestation statement on their notes. E/M (Evaluation and Management) services have several resident/attending scenarios.  Teaching physician documentation needs to make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care. Minimally acceptable documentation scenarios demonstrating the attending’s presence and participation are outlined below.

Scenario 1 – Teaching physician performs all of the elements of an E/M service independently. In the absence of a note by a resident, the teaching physician must document as he/she would document an E/M service in a nonteaching setting.

Minimally Acceptable Documentation Examples:

Admitting Note: “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

Follow-up Visit: “Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”

Follow-up Visit: “Hospital Day #5. I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.”

NOTE: In this scenario if there are no resident notes, the teaching physician must document as he/she would document an E/M service in a non-teaching setting.

Scenario 2 – The resident performs all of the elements of an E/M service in the presence of, or jointly with a teaching physician. The resident documents the service. In this scenario, the teaching physician must demonstrate in his/her attestation both their presence and participation in the E/M service. The teaching physician should reference the resident’s note in their statement.

Minimally Acceptable 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 Visit: “I saw the patient with the resident and agree with the resident’s findings and plan.”

Scenarios 3 & 4 – The resident performs all or some of the elements of an E/M service independently. Documents the service in the medical record. The teaching physician performs the critical/key portions of the service with or without the resident.  Discusses the case with the resident. The attending’s statement must demonstrate his/her presence and participation during the critical/key portions of the service. The teaching physician should reference the resident’s note in their statement.

Minimally Acceptable Documentation Examples:

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.”

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.”

Follow-up Visit: “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”

Follow-up Visit: “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”

Scenario 4 – Late Night Admissions

A late night admission according to CMS Transmittal 2303, is when a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day.

Scenario 4 Criteria:

1. The teaching physician must document their presence and participation. The teaching physician may reference the resident’s note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient’s condition has not changed, and the teaching physician agrees with the resident’s note.

2. The teaching physician’s note must reflect changes in the patient’s condition and clinical course that require that the resident’s note be amended with further information to address the patient’s condition and course at the time the patient is seen personally by the teaching physician.

3. The teaching physician’s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making regardless of whether the combination of the teaching physician’s and resident’s documentation satisfies criteria for a higher level of service.

Again, these examples are minimally acceptable examples for E/M teaching attestation statements. I cannot express how critical it is to make sure your attestations clearly indicate your presence and participation during the care of the patient for each encounter. It really comes down to, at the very least, revenue protection. It’s not enough to get paid anymore. The more extreme end of the spectrum, is protection from fraud and abuse allegations from an outside entity.

We will cover the only exception to these rules in a separate article – Teaching Physician Attestations – Primary Care Exception.

If you have questions about Teaching Physician Guidelines, please contact Jay.McVean@uth.tmc.edu or Caroline.Wolbrecht@uth.tmc.edu.