Is it insufficient documentation if both the resident and the teaching physician use macros only?
I work in a teaching facility and my experience is there are many macros within the template, including a statement that says he/she has personally reviewed the image and the resident’s interpretation and either agrees with it or edits the findings. I am told that the teaching physician can edit, add, delete any macro within the template that is compliant; is that a true statement? Do you know of any documentation that supports what is compliant? I do understand that Medicare does not pay for an interpretation if the teaching physician only countersigns the resident’s interpretation.
This is the definition from Chapter 12, Section 100 of Claims Processing Manual (IOM 100-4):
Documentation – Notes recorded in the patient’s medical records by a resident, and/or teaching physician or others as outlined in the specific situations below regarding the service furnished. Documentation may be dictated and typed or hand-written, or computer-generated and typed or handwritten. Documentation must be dated and include a legible signature or identity. Pursuant to 42 CFR 415.172 (b), documentation must identify, at a minimum, the service furnished, the participation of the teaching physician in providing the service, and whether the teaching physician was physically present.
In the context of an electronic medical record, the term ‘macro’ means a command in a computer or dictation application that automatically generates predetermined text that is
not edited by the user.
When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation if the teaching physician adds it personally in a secured (password protected) system. In addition to the teaching physician’s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. It is insufficient documentation if both the resident and the teaching physician use macros only.