A countersignature by itself is insufficient for both documentation and billing purposes.
According to CMS, at minimum, the following documentation must be included when billing for services provided by the intern/resident/fellow with a teaching physician:
- “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
- “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
- “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
Unacceptable documentation by a teaching physician includes the following examples with a countersignature:
- “I saw and evaluated the patient”
- “I reviewed the resident’s note and agree with the plan”
- “Agree with the above……”
- “Patient seen and evaluated…….”
- “Discussed with resident and agree with plan……….”
Download the complete tip, Documentation Issues Facing Providers Supervising Resident Physicians.