For E/M services, what should be done when the physician has met the teaching physician requirements?

When a physician has met the teaching physician requirements, it is necessary to combine both the resident's note and the teaching physician's note to accurately select the Evaluation and Management (E/M) code. This approach ensures that the documentation reflects the contributions of both the resident and the attending physician, ultimately providing a more comprehensive view of the service rendered.

The resident's documentation may contain details regarding the patient's history, examination findings, and medical decision-making, while the teaching physician's note may include specific contributions related to their supervision, teaching, and any additional findings or decisions made in conjunction with the resident's evaluation. By integrating these two pieces of documentation, the auditor or coder can ensure that all elements of the service are appropriately accounted for, leading to accurate coding and compliance with Medicare billing requirements.

This methodology is essential in teaching settings where residents are actively involved in patient care under the supervision of attending physicians, aligning with both medical coding standards and regulations that govern teaching physician involvement in resident care to maintain integrity and accuracy in billing practices.