CMS Updates Teaching Physician Services Guidance

Sept. 14 the Centers for Medicare & Medicaid Services (CMS) released Transmittal 2303 to rescind and replace Transmittal 2247, and to clarify guidance for teaching physicians. Specifically, the transmittal clarifies the use of residents with less than six months in a graduate medical education (GME) approved program and physician requirements when using modifier GC This service has been performed in part by a resident under the direction of a teaching physician. Instruction was previously issued with the wrong implementation date of Oct. 14, 2011, as well. The correct implementation date is July 26, 2011.

Know Scenario 4 Documentation Guidance

Certified Interventional Radiology Cardiovascular Coder CIRCC

In Transmittal 2303, CMS adds “Scenario 4” to the list of common scenarios for teaching physicians providing evaluation and management (E/M) services:

“When a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day:

  • The teaching physician must document that he/she personally saw the patient and participated in the management of the patient. The teaching physician may reference the resident’s note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient’s condition has not changed, and the teaching physician agrees with the resident’s note.
  • The teaching physician’s note must reflect changes in the patient’s condition and clinical course that require that the resident’s note be amended with further information to address the patient’s condition and course at the time the patient is seen personally by the teaching physician.
  • The teaching physician’s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making regardless of whether the combination of the teaching physician’s and resident’s documentation satisfies criteria for a higher level of service. For payment, the composite of the teaching physician’s entry and the resident’s entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician.”

CMS describes minimally acceptable documentation for this scenario as being:

Initial Visit: “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.”

Initial or Follow-up Visit: “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”

Follow-up Visit: “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”

Follow-up Visit: “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”

Examples of unacceptable documentation for this scenario:

  • “Agree with above,” followed by legible countersignature or identity
  • “Rounded, Reviewed, Agree,” followed by legible countersignature or identity
  • “Discussed with resident. Agree,” followed by legible countersignature or identity
  • “Seen and agree,” followed by legible countersignature or identity
  • “Patient seen and evaluated,” followed by legible countersignature or identity
  • A legible countersignature or identity alone

Such documentation is not acceptable because it does not make it possible to determine whether the teaching physician was present, evaluated the patient, and had any involvement with the plan of care.

HCPCS Level II Codes Included in Exception

Other changes state that, effective Jan. 1, 2005, HCPCS Level II code G0402 Initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first 12 months of Medicare enrollment is included under the primary care exception. And, effective Jan. 1, 2011, HCPCS Level II codes G0438 Annual wellness visit, including personal preventive plan service, first visit and G0439 Annual wellness visit, including personal preventive plan service, subsequent visit are included under the primary care exception.

Supervision Requirement Clarification

Teaching physicians submitting claims under this exception may not supervise more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability. Teaching physicians may include residents with less than six months in a GME approved residency program in the mix of four residents under the teaching physician’s supervision. The teaching physician must be physically present for the critical or key portions of services furnished by the residents with less than six months in a GME approved residency program. That is, the primary care exception does not apply in the case of residents with less than six months in a GME approved residency program.

Diagnostic Radiology and Other Diagnostic Tests

To bill for surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.

CMS says Medicare will pay for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician. If the teaching physician’s signature is the only signature on the interpretation, Medicare assumes he or she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she personally reviewed the image and the resident’s interpretation and either agrees with it or has edited the findings. Medicare does not pay for an interpretation if the teaching physician only countersigns the resident’s interpretation.

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