General Teaching Documentation and Coding Guidelines for Pathology

Title: General Teaching Documentation and Coding Guidelines for Pathology
Standard #:

DC-321

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

DEFINITIONS

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

STANDARD

The teaching physician must personally perform the interpretation or completely review and where appropriate, edit the resident’s interpretation in order to bill a fee. The medical record must be clear that the teaching physician actually reviewed the case. Countersignature only by the Teaching Pathologist is insufficient documentation.

The physical presence requirement for Teaching Pathologists is that the Teaching Pathologist must personally view the specimen or test result and confirm the interpretation by the Resident either alone or in the presence of the Resident. The documentation must include a written report that reflects that the Teaching Pathologist either personally examined or interpreted the results, or personally reviewed the Resident’s interpretation along with the original specimen of test. If the Teaching Pathologist’s signature is the only signature on the report, it will be assumed that the Teaching Pathologist personally performed the interpretation.

Electronic signatures on dictated pathology reports are acceptable as long as electronic default statements are not used in the place of patient specific documentation. Security systems must ensure that the electronic signature can only be applied by the physician.

REGULATORY REFERENCES

Medicare Claims Processing (PUB. 100-04)
Chapter 12 – Physicians/Nonphysician Practitioners
100 – Teaching Physician Services (Updated through Rev. 2303 **Rescinds and Replaces Transmittal #2247, dated 06/24/11**; Effective: 06/01/11; Issued: 09/14/11)

QUESTIONS

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.