• Industry News
  • Access and Reimbursement
  • Law & Malpractice
  • Coding & Documentation
  • Practice Management
  • Finance
  • Technology
  • Patient Engagement & Communications
  • Billing & Collections
  • Staffing & Salary

Coding and Teaching

Article

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.

Recent Videos
Bhavesh Vadhani
Bhavesh Vadhani
Bhavesh Vadhani
Physicians Practice | © MJH LifeSciences
The importance of vaccination
The fear of inflation and recession
Protecting your practice
Protecting your home, business while on vacation
Protecting your assets during the 100 deadly days
Payment issues on the horizon
Related Content
© 2024 MJH Life Sciences

All rights reserved.