General Teaching Documentation and Coding Guidelines for Psychiatric Services

Title: General Teaching Documentation and Coding Guidelines for Psychiatric Services
Standard #:


Issued: 12/01/1997 Reviewed/Revision Date: 08/21/2000, 10/06/2009, 07/01/2012, 12/09/2014


Teaching Physician – A physician (other than another resident) who involves residents in the care of his or her patients

Resident – An individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.  The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the Fiscal Intermediary.  Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of “resident”.  Additionally, this status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents

Physically Present – For certain psychiatric services, the requirement for the presence of the teaching physician during the service may be met by concurrent observation of the service by use of a one-way mirror or video equipment.


For psychiatric services, including evaluation and management services, furnished under an approved psychiatric GME program, the teaching physician will be considered to be present during each visit for which payment is sought as long as the teaching physician observes the visit through visual devices (i.e., one-way mirror or videotape*) and meets with the patient after the visit.

  1. The physician must view the session while it is being conducted and must document in the medical record accordingly.
  2. Psychotherapists can only bill for the amount of time they actually spend supervising a therapy session, not the amount of time the resident spent providing the session.
  3. For Medicare, psychologists may not supervise psychiatric residents in approved GME programs. Psychologists cannot bill for evaluation and management services rendered to a Medicare member.

* Audio-only equipment does not meet the exception to the physical presence requirement.


MCP 100-04 Chapter 12-100.1.3 Revision 811, issued: 1/13/06, Effective 01-01-06, Implementation 2/13/06


Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Help & Reporting Line at (213) 740-2500 or (800) 348-7454.