June 2022
Volume 63, Issue 7
Open Access
ARVO Annual Meeting Abstract  |   June 2022
Compliance with Documenting the Presence of a Teaching Physician in a Resident Ophthalmology Clinic
Author Affiliations & Notes
  • Kent L Anderson
    Ophthalmology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
  • Angelica I Garcia
    Ophthalmology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
  • Footnotes
    Commercial Relationships   Kent Anderson None; Angelica Garcia None
  • Footnotes
    Support  None
Investigative Ophthalmology & Visual Science June 2022, Vol.63, 1069 – A0164. doi:
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      Kent L Anderson, Angelica I Garcia; Compliance with Documenting the Presence of a Teaching Physician in a Resident Ophthalmology Clinic. Invest. Ophthalmol. Vis. Sci. 2022;63(7):1069 – A0164.

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      © ARVO (1962-2015); The Authors (2016-present)

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Abstract

Purpose : Supervision must be documented for every patient encounter during residency training. This is especially indicated when a bill is submitted to a payor for services performed with the involvement of a resident. (1) The teaching physician must include an attestation documenting the level of resident involvement in the patient encounter. (2) When submitted to CMS the GC modifier is also utilized to indicate that a resident, under the direction of a teaching physician, is involved in a patient encounter. We retrospectively reviewed our documentation of the teaching physician in a resident ophthalmology clinic.

Methods : All patient encounters performed by ophthalmology residents over a 5-month period (January thru May 2021) were retrospectively reviewed for appropriate documentation of the teaching physician. All patient encounters were supervised by teaching physicians in an outpatient ambulatory ophthalmology clinic at the Texas Diabetic Institute, San Antonio, TX. Each electronic medical record (EMR) was reviewed for appropriate documentation of the teaching attestation and GC modifier. The data was analyzed using R software.

Results : A total of 1,500 patient encounters were reviewed. All records (100%) documented the teaching attestation. The GC modifier was utilized in 1,388 of patient encounters (92.5%). January (95%) and May (88%) showed the highest and lowest compliance, respectively. The GC modifier was not documented in 7.5% of patient encounters.

Conclusions : All patient encounters included appropriate documentation of the teaching attestation. Residents in clinic have direct supervision by the teaching physician and the EMR sends all notes to teaching physicians to be signed and attested. In addition, all notes are reviewed internally for compliance and are amended if not documented appropriately. Compliance with the GC modifier was significantly lower. This is attributed to inadequate understanding of proper usage and that it may not be required by all payors. With recent increase emphasis on the attestation for all notes, providers are less enthusiastic to also ensure documentation of the GC modifier due to this redundancy. Good practices aim for 100% compliance in documentation. Both teaching and resident physicians should be educated on appropriate supervision and how it should be best documented in the medical record.

This abstract was presented at the 2022 ARVO Annual Meeting, held in Denver, CO, May 1-4, 2022, and virtually.

 

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