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Understanding Resident Supervision

Rebecca England, MHA, RHIA, CCP
Co-Chair VHA HIM Coding Council

"Resident Supervision", two words that carry a lot of weight in the Department of Veterans Affairs (VA). VHA Handbook 1400.1, Resident Supervision places responsibility for establishing policies and processes for monitoring resident supervision with the facility Designated Education Officer (DEO) or Associate Chief Of Staff (ACOS) for Education at the local level. As many of us in the field have found out, monitoring and auditing of documentation requirements often falls to the Health Information Management Service (HIMS) and/or Compliance and Business Integrity (CBI) program.

Resident supervision guidelines have undergone many changes during recent years due to internal VA concerns and public attention focused on the VA's program. The most recent version of the handbook has incorporated VA's focus on high quality care and supervision appropriate to training requirements.

The Resident Supervision handbook specifies the monitors that must be completed in order to "monitor the adequacy of supervision", whenever residents are involved. The specific areas of care to monitor include:

  • Inpatient
  • Outpatient
  • Procedures (clinics and bedside)
  • Emergency care
  • Consults
  • Surgeries (including 100% review of level E/F OR cases)

So what role do we as HIMS, CBI and even billing professionals play in the resident supervision game? Educator? YES! We are teachers for our provider staff, we are the ones that must read, interpret, and understand the specific requirements of the handbook in order to monitor. Education of our provider staff, both attendings and residents, must occur first if our compliance with current guidelines is going to be attained. Monitor/Auditor? RIGHT AGAIN! Most facilities utilize the HIMS and CBI program to assist the clinical services and ACOS/E with performing these functions due to the relationship of resident supervision to documentation and billing requirements, which fall into the realm of these services.

With all the different requirements outlined in VHA Handbook 1400.1, what are the "Hot Issues" on which sites should focus ?

1) Physical Presence requirement: Did you know that a supervising attending physician must be physically present in:

  • All outpatient clinics (involving residents)
  • Emergency departments (when residents care for patients)
  • All operating room cases (minimum requirement - in OR suite)

Exceptions:

  • Emergency Cases (as defined in 1400.1)
  • Non-OR cases, done in the OR, but truly are considered bedside/clinic procedures
  • All non-routine, non-OR procedures (in a procedure room or suite)

2) Documentation Requirements: VHA Handbook 1400.1 states that the medical record must clearly demonstrate the involvement of the supervising practitioner in each type of resident patient encounter.

Documentation must be entered into the medical record by the supervising practitioner or reflected within the resident progress note or other appropriate entries in the medical record (e.g. procedure reports, consultations, discharge summaries). Pathology and radiology reports are an exception; these must be verified by a supervising practitioner.

For most purposes four (4) types of attending entries/documentation are allowed:

  1. Independent progress note
  2. Addendum to resident note
  3. Co-Signature (not additional signer) of resident note
  4. Reflected in resident's note (e.g. Attending of record for this patient encounter is Dr. X)

There are some situations that require an independent note/addendum by the attending:

  1. Inpatient acute admission (initial note) (including ICU)
  2. Extended care admission
  3. Pre-Op/Procedure Assessment
  4. Interward/Interservice transfers (including ICU - when there is a change in attending)

So what does all this mean? Coordination, cooperation and communication are all key to having successful compliance with all aspects of resident supervision. If physical presence and documentation requirements are met, we are then able to bill third-party insurance carriers for resident services.

Beginning January 1, 2006, when care is provided in whole or in part by a resident and documentation shows the resident was supervised in accordance with VA policy, coding staff are to assign modifier "GR" to each CPT code in order to denote care provided by a resident under the direction of a teaching physician.