Coding and Teaching

November 1, 2005

How do we code this teaching physician scenario? The patient complains of nasal congestion, cough, and fever. A first-year resident does a complete head-to-toe exam. A more experienced physician (the teaching physician) only examines the upper respiratory system. Does the teaching physician code this at a lower E&M because he knows the full exam was not necessary, or code the complete exam because he is supervising the resident, and the resident did do the full exam?

Question: How do we code this teaching physician scenario? The patient complains of nasal congestion, cough, and fever. A first-year resident does a complete head-to-toe exam. A more experienced physician (the teaching physician) only examines the upper respiratory system. Does the teaching physician code this at a lower E&M because he knows the full exam was not necessary, or code the complete exam because he is supervising the resident, and the resident did do the full exam?

Answer: According to Emily Hill of Hill & Associates, the teaching physician should bill for the level of service necessary to appropriately evaluate and manage the patient's presenting problem(s). Therefore, in the scenario you present, it appears that the teaching physician should report a lower level of E&M code than what might be possible using the resident's documentation. The level of service is determined not only by the extent of the history and examination but also by the medical necessity of the care.