Jamie Frantz CEMC, CPC
Aegis Compliance and Ethics Center, LLC
Teaching Physician Guidelines
In 2012, through the Comprehensive Error Rate Testing (“CERT”) program, Medicare Administrative Contractors (“MAC”s) identified an estimated $29.6 billion improperly paid during the 2012 federal fiscal year. Payments made for services provided in a teaching setting due to improper documentation for Teaching Physician Services was one of the findings.
Documentation and Billing Requirements for Teaching Physicians.
Medicare pays for services furnished in a teaching setting through the Medicare Physician Fee Schedule (“MPFS”). Medicare has criteria that must be met for payment of such services:
- The services are personally furnished by a physician who is not a resident.
- Services are furnished by a resident when a teaching physician is physically present during the critical or key portions of the service.
- Services are furnished by a resident under a primary care exception within an approved Graduate Medical Education (“GME”) program.
The Teaching Physician must personally document:
- That he/she performed the service or was physically present during the key or critical portions of the service furnished by the resident.
- His/her participation in the management of the patient.
Both the Teaching Physician and resident entries when combined, must support the medical necessity of the service performed. Documentation by the resident of the presence and participation of the Teaching Physician is not sufficient. In cases where a resident has written notes, the Teaching Physician’s notes may reference the resident’s note.
Services furnished by a Teaching Physicians involving a resident in the care of their patients must be identified on the claim. Claims for these services must include the GC modifier (the service has been performed in the part by a resident under the direction of a Teaching Physician).
When a Teaching Physician personally performs all the required elements of an evaluation and management (“E/M”) service without a resident, the Teaching Physician must document as he/she would document an E/M service in a nonteaching setting.
Exception for E/M services Furnished in Certain Primary Care Centers.
Medicare may grant a primary care exception for low- or mid-level E/M services (99201-99203 and 99211-99213) and HCPCS codes (G0402 and G0438-G0439) performed by the resident when the Teaching Physician is not present.
The primary care center must attest in writing that all of these conditions are met:
- Services are provided in a primary care center located in the outpatient department of a hospital or another ambulatory care setting in which the time spent by residents in patient care is included in determining the DGME payments to a teaching hospital.
- Residents must complete more than 6 months of an approved residency program.
- The Teaching Physician may supervise no more than four residents at any given time.
- The Teaching Physician must have no other responsibilities, including supervision of other staff, at the time services are provided by residents.
- The Teaching Physicians must ensure that the care furnished is reasonable and necessary.
- The Teaching Physicians must review the care furnished by the residents during or immediately after each visit.
- The Teaching Physician must document the extent of his/her participation in the review and direction of services provided to the patient.
- The primary care center is considered the patient’s primary location for health services and the residents are expected to generally furnish care to the same group of established patients during their residency training.
- Residency programs likely to qualify for the primary care exception include family practice, general internal medicine, geriatric medicine, pediatrics and obstetrics/gynecology. Certain GME programs in psychiatry may qualify in special situations.
- Services provided under the primary care exception must be identified on the claim. Claims for these services must include the GE modifier (service has been performed by a resident without the presence of a teaching physician under the primary care exception).
Examples of Acceptable and Unacceptable Documentation by a Teaching Physician.
- I performed a history and physical examination of the patient and discussed his/her management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.
- I saw and evaluated the patient. I agree with findings and the patients plan of care as documented in the resident’s note.
- I saw and examined the patient. I agree with the resident’s note except the high blood pressure, so I will order blood work to evaluate.
- Agree with above.
- Rounded, reviewed, agree.
- Discussed with resident. Agree.
- Seen and agree.
- Patient seen and evaluated.
While overpayments for services provided in a teaching setting still seems to be an issue. As an auditor it’s important to give feedback and educate Teaching Physicians, when improper documentation is being done to support medical necessity.