What are the documentation requirements for hospital visits in a teaching facility?

Answer
Physician services to patients in a teaching facility are covered under Part B. Documentation can be typed, dictated, handwritten or computer-generated. Documentation must include the patient’s name, date of service, and legible signature or identity of the person entering the information and performing the service. Documentation must also identify, at a minimum:

  • The service furnished
  • The participation of the teaching physician in providing the service
  • Whether the teaching physician was physically present. The teaching physician must personally document:
    • He/she performed the service or was physically present during the key or critical portions of the service when performed by a resident
    • His/her participation, as a teaching physician, in the management of the patient

Resource: CMS guidance regarding teaching physicians and documentation is available in the CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, Section 100 (PDF, 1.05 MB).

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