July 15: Final revisions are being made to a clarifying statement from CMS. This will probably be incorporated into the manual because of the importance of this subject to teaching physicians. Jan 13: From Transmittal 811 (linked below): 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.
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Transmittal 811
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