I Take Exception with That!

Understand the Medicare Primary Care Center Exception.

By Maryann C. Palmeter, CPC, CENTC

The final rule for teaching physician presence and documentation requirements under Medicare Part B has been in effect since July 1, 1996. Over the years, the Centers for Medicare & Medicaid Services (CMS) has issued changes and clarifications to the rule. Most recently, CMS authorized the addition of new annual wellness visit codes G0438 and G0439 to the list of services that can be performed under the “Primary Care Center Exception” (refer to CMS Transmittal 2303, Change Request (CR) 7378, dated Sept. 14, 2011).

Evaluation and Management – CEMC

CMS also added specific manual language (Medicare Claims Processing Manual, Pub. 100-04, chapter 12, sections 100.1 and 100.1.1 (C)) to clarify how the Primary Care Center Exception would apply when the teaching physician is supervising a resident with six months or less in an approved Graduate Medical Education (GME) residency program, as well as residents with more than six months in such a program.

Follow the General Teaching Physician Rule

Services furnished by residents in residency programs are excluded from being paid as “physician services” under Medicare Part B because the Medicare fiscal intermediary, Medicare Part A, already pays teaching hospitals for the services of interns and residents, and the costs associated with the supervisory services of teaching physicians. Ordinarily, to be reimbursed under Medicare Part B, services furnished in teaching settings must meet one of the following requirements:

  • The service must be personally furnished by a physician who is not a resident.
  • The service must be furnished by a resident where a teaching physician was physically present during the critical or key portions of the service.
  • The service provided must be a specified service (See the Applicable Procedure Codes information box) furnished by a resident under the Primary Care Center Exception.

What Is the Primary Care Center Exception?

An exception to the general teaching physician rule is sometimes referred to as the “Primary Care Center Exception,” but this exception is not limited to primary care or family practice residency programs. Per CMS, the exception could apply to any residency program with requirements that are incompatible with the teaching physician physical presence requirement. This is because in some residencies, the resident is the patient’s primary caregiver, and it is beneficial for the resident to see patients alone to learn medical decision-making, and to recognize his or her own limitations. Direct teaching physician involvement in these cases may negatively affect the patient-resident relationship. Some examples of residency programs most likely to qualify for the exception are: family practice, general internal medicine, geriatrics, and pediatrics.

Specified services performed under the exception may be billed to Medicare Part B under the teaching physician’s provider number, without the need for the teaching physician to personally perform the service or to be physically present during the critical or key portions of the service.

Attest in Writing

For the exception to apply, the center must attest in writing to the Medicare Part B administrative contractor (MAC) that the following conditions have been met:

  1. The services are performed in a center that is located in an outpatient department of a hospital or another ambulatory care entity in which the time spent by the residents in patient care activities is included in determining Medicare Part A payments to the hospital.
  2. The residents involved have completed more than six months of a residency program.
  3. The teaching physician directs the care of no more than four residents at a time and directs the care from such proximity as to constitute immediate availability.
  4. The teaching physician has no other responsibilities at the time (including the supervision of other personnel) and assumes management responsibility for those patients seen by the residents.
  5. The patients seen are an identifiable group who consider the center to be the continuing source of their health care and are cognizant that services are furnished by residents under the medical direction of teaching physicians. The residents must generally follow the same group of patients throughout the course of their residency program.

Centers exercising the exception must maintain records demonstrating they qualify for the exception.

Teaching Physician Documentation Requirements Under the Exception

The teaching physician must document the extent of his or her participation in the review and direction of the services furnished to each patient.

Teaching Physician Note Example

I have reviewed with the resident Jane Doe’s medical history, physical examination, diagnosis, and results of tests and treatments and agree with the patient’s care as documented in the resident’s note.

Services Included Under the Exception

The range of services furnished by residents under the exception includes:

  • Acute care for undifferentiated problems or chronic care for ongoing conditions, including chronic mental illness
  • Coordination of care furnished by other physicians and providers
  • Comprehensive care not limited by organ system or diagnosis

Know Procedure Code Restrictions

Under the exception, MACs may make physician fee schedule payment for reasonable and necessary, low- to mid-level evaluation and management (E/M) services, and other specified services, when furnished by a resident without the presence of a teaching physician. Refer to the Applicable Procedure Codes information box for a list of specific procedure codes that may be billed under the exception.

Append Modifiers Properly

Modifier GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception must be appended to services billed under the exception. Services furnished in a primary care exception center that do not meet the requirements for the exception would revert to the general teaching physician rule for services furnished outside of a primary care exception center. Modifier GC This service has been performed in part by a resident under the direction of a teaching physician would be appended to these services.

Applicable Procedure Codes

CPT® Codes

New patient office or other outpatient visit: 99201, 99202, and 99203

Established patient office or other outpatient visit: 99211, 99212, and 99213

HCPCS Level II Codes

G0402                  Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment

G0438                  Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit

G0439                  Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit

Follow 4-to-1 Ratio Rules

As mentioned, the teaching physician under whose name payment is sought must not supervise more than four residents at any given time. CMS recently provided manual guidance clarifying that teaching physicians may include residents with less than six months in a residency program in the mix of four residents under the teaching physician’s supervision. The teaching physician would have to be physically present for the critical or key portions of the services furnished by the resident with less than six months in a residency program. That is, the exception would not apply in the case of the resident with less than six months in a residency program. Because the exception would not apply in this case, modifier GC would be appended to the service, rather than modifier GE. The fact that one or more of the residents has less than six months in a residency program does not affect the application of the exception to the other  residents with more than six months in a residency program. The 4-to-1 ratio of residents to teaching physician must not be exceeded, in any case.

Sample Scenarios with 4-to-1 Ratio

dec-clearance-sale

Resident with 6 months or less in residency program.

New resident A

Resident with more than 6 months in residency program.

Old resident B

Resident with more than 6 months in residency program.

Old resident C

Resident with more than 6 months in residency program.

Old resident D

 

Exception applies to old residents B, C, and D, but not to new resident A. Follow general TP rules for new resident A.

Apply modifier GC to charge for new resident A. Apply modifier GE to charges for residents B, C, and D.

Resident with 6 months or less in residency program.

New resident A

Resident with more than 6 months in residency program.

Old resident B

Resident with more than 6 months in residency program.

Old resident C

Resident with more than 6 months in residency program.

Old resident D

Resident with more than 6 months in residency program.

Old resident E

Exception does not apply to ANY residents because the 4-to-1 ratio is exceeded. Follow general TP rules for ALL residents.

Apply modifier GC to charges for ALL residents.

Resident with 6 months or less in residency program.

New resident A

Resident with 6 months or less in residency program.

New resident B

Resident with more than 6 months in residency program.

Old resident C

Resident with more than 6 months in residency program.

Old resident D

 

Exception applies to old residents C and D, but not to new residents  A and B. Follow general TP rules for new residents A and B.

Apply modifier GC to charges for residents A and B and modifier GE to charges for residents C and D.

 

Become Familiar with These Key Definitions

Resident

An individual who participates in an approved graduate medical education (GME) program, or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary (Medicare Part A). Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of “resident.” This status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents. This term is not applicable to medical students.

Teaching Physician

A physician (other than a resident) who involves residents in the care of his or her patients.

Teaching Hospital

A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry.

Teaching Setting

Any provider, hospital-based provider, or non-provider setting in which Medicare payment for the services of residents is made by Medicare Part A under the direct GME payment methodology or freestanding skilled nursing facilities (SNFs) or home health agencies (HHAs) in which such payments are made on a reasonable cost basis.

Physically Present

The teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and performs a face-to-face service.

 

Maryann C. Palmeter, CPC, CENTC, is director of physician billing compliance for University of Florida Jacksonville Healthcare, Inc., and provides professional direction and oversight to the billing compliance program at the University of Florida College of Medicine-Jacksonville. She has over 29 years of health care experience in both government contracting and physician billing. She is the education officer and two-time past president of the Jacksonville, Fla. chapter. Ms. Palmeter is AAPC’s 2010 Member of the Year, and is a member of the AAPC National Advisory Board.

 

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One Response to “I Take Exception with That!”

  1. Clara says:

    1996 GC & GE Medicare definitions from AAPC

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