The Centers for Medicare and Medicaid Services have published specific guidelines and requirements that need to be met when seeking payment from Medicare. These regulations speak to the services furnished by not only the teaching physician, but the resident and medical student.
The "general rule", as described by the American Association of Medical Colleges (AAMC), is "if a resident participates in a service furnished in a teaching setting, a physician fee schedule payment is made only if a teaching physician is present to perform or observe the resident perform the key portion of any service or procedure for which payment is sought." Information recorded within the medical record must demonstrate the teaching physician's presence and level of participation in the service.
For billing purposes, the medical record information must also support the presence and direct participation of the teaching physician during the critical/key (most important treatment-determining, interpretation making, defining technology or technique) portion of the service or procedure, and medical decision making.
Through the link below, you will find information involving general documentation guidelines including those for Evaluation and Management Services that will help guide in the process of patient care and properly coding and billing for all medical services provided at UCLA Health System.
