Through Carriers Manual Transmittal 1780, effective November 22, 2002, CMS has added significant detail to the provisions governing documentation of services furnished by teaching physicians with the involvement of residents. The revisions make clear that a teaching physician is not required to repeat documentation previously provided by a resident, and that the documentation of both the resident and the teaching physician is combined for purposes of assignment of service codes. The revisions even include examples of "minimally acceptable" and "unacceptable" documentation" for various scenarios. For example, in the case of a follow-up hospital visit where the resident sees the patient prior to the teaching physician, the following is acceptable: "See resident’s note for details. I saw and evaluated the patient and agree with the findings and plans as written." "Patient seen and evaluated," followed by a countersignature, is not acceptable. Other revisions address surgical procedures, radiology, documentation by students, and services furnished in primary care centers.

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