Frequently Asked Questions

How should a TP document his/her services when a resident admits a patient to the hospital late at night and the TP does not see the patient until the next calendar day? According to Transmittal 2247 (Change Request 7378) dated June 24, 2011 from the Centers for Medicare and Medicaid Services (CMS): To support the service provided to the patient by the TP, the TP should document he/she personally saw and participated in the management of the patient. The TP may reference the resident’s note to support the service he/she is billing provided that the patient’s condition has not changed substantially since admission and the TP agrees with the resident’s note. The TP’s note must include any supplemental information necessary to reflect the change in the patient’s condition and clinical course between the time of admission and when the TP personally saw the patient. The date of service for the TP’s professional service(s) must be the date he/she personally saw and participated in the management of the patient.

According to Transmittal 2247 (Change Request 7378) dated June 24, 2011 from the Centers for Medicare and Medicaid Services (CMS):

To support the service provided to the patient by the TP, the TP should document he/she personally saw and participated in the management of the patient. The TP may reference the resident’s note to support the service he/she is billing provided that the patient’s condition has not changed substantially since admission and the TP agrees with the resident’s note.
The TP’s note must include any supplemental information necessary to reflect the change in the patient’s condition and clinical course between the time of admission and when the TP personally saw the patient. The date of service for the TP’s professional service(s) must be the date he/she personally saw and participated in the management of the patient.