DEAR DR. ROACH: When I have appointments with my physicians (at our local, highly rated academic health system), they no longer do a physical exam. But in the after-visit note, there is a documented and complete physical exam that doesn’t reflect reality. This happened on all types of visits, including annual visits and pre- and post-surgery visits.

If I am examined by a resident, the attending physician will attest in the after-visit note to having examined me alongside the resident when, in actuality, the physician was not in the room. I find this appalling, but it seems to be common practice. These doctors are billing for services that they do not deliver. Do you see any effort in the medical world to respond to this? — J.H.

ANSWER: The new electronic medical record systems make it easy to document a complete physical exam, sometimes with a single click. If this happens once, it’s a mistake. If it happens consistently, this is at least a system error, if not deliberate deception. The term used in the industry is “upcoding” because documentation of a complete examination allows for higher billing to the insurance company.

Physicians need to be very careful not to document a physical exam that they didn’t do. A less-kind word for consistently doing this practice is “fraud.” Penalties can be tens of thousands of dollars per false claim.

The rules for resident supervision are complicated. In general, billing can only be done for services that are provided by or under the direct supervision of the attending physician. There are exceptions to this, such as resident physicians who provide primary care. However, once again, saying that you were there supervising the resident when you weren’t is against the law.

Now if the attending physician comes in the room and asks questions to confirm the key findings of your medical history, they do not have to do a complete examination to fulfill the obligations for the primary care exemption.

Outside of primary care, the attending physician must be physically present for the key portions of the services being billed.

DEAR DR. ROACH: I saw your recent column about the wife with intractable depression. I can relate, but you barely glanced over what has been life-changing for me as a treatment: TMS (transcranial magnetic stimulation).

It is quick, easy and painless, and most insurance (even Medicare) companies fully cover it. To be frank, Doc, not nearly enough suffering people have ever even heard of TMS as an option. Would you illustrate to your readers just a tad more about how powerful it can be as a treatment option? — R.F.W.

ANSWER: Most people with depression respond well to treatment with a combination of psychotherapy and one of the standard medications, but some people need to try several medications before they find one that works. Unfortunately, there are people who do not get good results with medication. TMS is an option in these situations (but you don’t have to fail multiple medications to try TMS).

Even in people who have failed multiple medications, about 30% will have “marked” improvement or a resolution of their symptoms. TMS doesn’t cure everybody, but I agree that it’s a therapy that needs to be more widely used. The biggest problem is that it isn’t available everywhere.