Coding, billing,
and documentation tips for teaching physicians, interns, residents, and
students
But coding is
only one piece of the reimbursement puzzle. First it’s important to define who
is providing care and who is providing the oversight/proctoring/mentoring for
the intern, resident, or student.
Third-party
payers may or may not follow CMS’ guidelines. To confirm, contact those payers
to make sure they will recognize any billing for services provided by an
intern, resident, or student.
CMS definitions
Teaching
physician: A physician,
other than an intern or resident, who involves residents in the care of his or
her patients. Generally, the teaching physician must be present during all
critical or key portions of the procedure and immediately available to furnish
care during the entire encounter in order for the service to be payable
under the Medicare Physician Fee Schedule.
Intern or
resident: An individual
who participates in an approved Graduate Medical Education (GME) Program or a
physician who is authorized to practice only in a hospital setting (e.g., has a
temporary or restricted license or is an unlicensed graduate of a foreign
medical school). This definition includes interns, residents, and fellows in
GME Programs approved for direct GME and Indirect Medical Education (IME)
payments by fiscal intermediary (FI)/Medicare administrative contractor (MAC).
Student: An individual
who participates in an accredited educational program (e.g., medical school)
that is not an approved GME Program and is not considered an intern or
resident. Medicare does not pay for any services furnished by a student.
Medical students are not licensed physicians.
Payment for
services
Now that you
know the roles of individuals in a teaching physician setting, next you must
determine what service is being provided, and if your facility will be
reimbursed for that service.
According to
CMS, Medicare will pay for medical or surgical services provided by a licensed
physician in a teaching setting.
CMS will pay
for services provided by a resident if a “teaching physician is present during
critical or key portions of the service or procedure.” In some of Medicare’s
information the term “physically present” will be noted. This simply means the
teaching physician and the resident physician are together with the patient in
the same room or exam area.
Unfortunately
CMS does not elaborate on what it considers “critical or key portions” of the
service the resident provides. The teaching provider must decide what it
considers critical or key portions of the service provided. In the absence of
more definitive guidelines, it is vital that both the resident and teaching
physician document the services they provide. That way both providers can show
when the supervising physician was present and what the supervising physician
believed to be the key or critical portions of the service.
CMS requires
strict adherence to it guidelines in order for it to reimburse the provider of
the service. Most third-party payers will default to CMS’ guidelines. However,
some third-party insurers have their own guidelines, and may or may not pay
when a resident has seen the patient and provided services. Someone in your
organization may need to call that third-party payer to ensure compliance with
its policies, especially if you are contractually bound to that payer.
Documentation
criteria and guidance for the teaching physician
If your
provider is serving as a teaching physician or oversight physician, he or she
must clearly document:
Participation
in the review of the history/chief complaint of the patient as taken by the
intern/resident and/or student
- Participation in the management of the patient to include the examination and medical decision-making
- Physical presence during the “critical or key” portions of the service/procedure provided by the intern/resident and/or student
If a surgical procedure is performed, the teaching physician must be present during all critical and key portions of the procedure, and must be immediately available to step in and take over care if needed. Anyone involved in the surgical area, such as a surgical assistant, nurse, or staff member assigned as a scribe can document the information. If the procedure takes fewer than five minutes to perform, this is considered a minor procedure, and the teaching physician must be present during the entire procedure.
If a radiological or pathological test is performed, the resident may perform that diagnostic testing, but again the teaching physician will need to verify that the test was medically necessary. The resident physician must document and sign the interpretation. The teaching physician must also indicate that he or she reviewed the interpretation and note whether he or she agrees or disagrees with the findings. The teaching physician does not have to be present during the testing or for pathology or laboratory interpretation by the resident. Teaching physicians only need to carefully review and document their findings in addition to the residents’ findings.
Coders and
billers will need the combined entries from the teaching physician and the
intern/resident and/or student to support the medical necessity of the care of
the patient, and to bill Medicare or another third-party payer.
Documentation of a service or procedure provided by the resident only—with a notation stating the teaching physician’s presence and participation— is not sufficient to bill CMS for that service.
The documentation must clearly indicate which portions of the service were provided by the teaching physician, intern, resident, or student.
Documentation of a service or procedure provided by the resident only—with a notation stating the teaching physician’s presence and participation— is not sufficient to bill CMS for that service.
The documentation must clearly indicate which portions of the service were provided by the teaching physician, intern, resident, or student.
Unacceptable
documentation
Unacceptable
documentation by a teaching physician includes the following examples with a
countersignature:
- “I saw and evaluated the patient”
- “I reviewed the resident’s note and agree with the plan”
- “Agree with the above……”
- "Patient seen and evaluated…….”
- “Discussed with resident and agree with plan……….”
A
countersignature by itself is insufficient for both documentation and billing
purposes.
According to
CMS, at minimum, the following documentation must be included when billing for
services provided by the intern/resident with a teaching physician:
"I
performed a history and physical examination of the patient and discussed his
management with the resident. I reviewed the resident's note and agree with the
documented findings and plan of care."
- "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."
- "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
Both the
resident/intern and the teaching physician must have separately identifiable
documentation, and clarity regarding their physical, face-to-face attendance
with the patient.
Coding and
billing for services provided by resident/intern and teaching physician
If the service
that was provided is a time-based code, such as code 99238 (hospital day
discharge management, 30 minutes or less) or 99239 (hospital day discharge
management, more than 30 minutes), the teaching physician must be present for
the entire period of time specified by the code.
With code
99239, 30 minutes or more does not specifically note “face-to-face” time. As
long as the documentation by the teaching physician details that the time took
more than 30 minutes, it should be sufficient for billing purposes.
In the case of
critical care time, in order to report code 99291 (critical care, evaluation
and management of the critically ill or critically injured patients; first
30-74 minutes), this time must be face-to-face with the patient, and the
teaching physician must be present for the entire period of time.
The same holds
true for E/M codes. If the provider wants to bill for a time-based E/M code,
then 50% of the total time spent must be face-to-face with the patient and the
provider must document that he or she spent that 50% counseling and
coordinating care with the patient.
When coding and
billing for teaching physicians, CMS requires the use of modifier -GC (this
service has been performed in part by a resident under the direction of a
teaching physician), or -GE (this service has been performed by a resident
without the presence of a teaching physician under the primary care exception).
Medicare
requires these two modifiers on the CMS 1500 claim form to provide information
in respect of teaching physician service. The use of the modifier does not
increase or decrease the payment to the teaching physician. If you are billing
for a third-party payer, that payer may or may not want either of these
modifiers included.
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