What are the Rules?

By Patricia Champion, CPC

If the teaching physician notes, “rounded, reviewed, agree,” will the documentation meet the strict requirements of your carrier?

When a medical student and resident both document in the medical record, what can the teaching physician bill? What exactly must the teaching physician document to bill for the service? Can the resident and teaching physician add their time together for time-based codes?
To resolve these questions, you should first know that the documentation of a resident and teaching physician must identify, at a minimum, the service furnished, the participation of the teaching physician and whether the teaching physician was physically present.
Medicare states that when using an electronic medical record, it is acceptable for the teaching physician to use a macro for personal documentation, as long as it is password-protected in the system. However, the teaching physician and the resident cannot use macros only. Customized information must support the medical necessity and describe the specific services furnished to the patient on that specific date. When the teaching physician reports his or her attestation to the resident’s note, modifier GC should be appended to the E/M service.
If a teaching physician personally performs all of the required elements of an E/M service without a note by a resident, the teaching physician should bill for the E/M service as though he or she were in a non-teaching setting. An example of an admitting note is, “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.”
If the resident performs the elements of the E/M service in the presence of (or jointly with) the teaching physician and the resident documents the service, the teaching physician must still document that he or she was present during the critical or key portion of the service and was directly involved in the management of the patient. Again, the two notes must be combined to determine the level of service. Medicare provides this example of the teaching physician’s attestation on an admitting note: “I was present with the 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.” A follow-up visit might state: “I saw the patient with the resident and agree with the resident’s findings and plan.”
If the teaching physician is absent during any of the required elements that the resident has documented, the teaching physician must independently perform the critical or key portion of the service with or without the resident present and discuss the case with the resident. The teaching physician must document that he or she personally saw the patient, performed the critical or key portions of the service and participated in the management of the patient. The teaching physician’s note should reference the resident’s note to facilitate combined billing.
Medicare provides this example of a teaching physician’s attestation for an 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.”
Medicare offers the following examples of unacceptable documentation. These examples don’t convey whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care:

• “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 evaluated,” followed by legible countersignature or identity.
• A legible countersignature or identity alone.

If time-based codes are reported, the teaching physician must be present for the period of time for which the claim is made. Time spent by the resident in the absence of the teaching physician cannot be added to time spent by the resident and teaching physician together or time spent by the teaching physician alone with the patient. When medical students see patients, the teaching physician or resident must be present. The student may document in the medical record, but if the student documents E/M services, the teaching physician must verify the review of systems and past, family and social history, re-document the history of present illness and perform the physical exam and medical decision-making.
Exception for Some E/M Services
An exception to this rule exists for E/M services furnished in certain primary care centers including family practice, general internal medicine, geriatric medicine, pediatrics and OB/GYN.
When the primary care center is granted a primary care exception, the teaching physicians may bill Medicare for the residents’ lower and mid-level E/M services, including services for new patients (99201-99203) and established patients (99211- 99213). These residents may also report G0344 for new patients during the first six months of Medicare enrollment. After the teaching physician documents the attestation, modifier GE must be appended to the E/M service. Under this exception, residents providing billable patient care services without the presence of a teaching physician must have completed at least six months of a GME-approved residency program, and the services must be provided in a center located in the outpatient department of a hospital or other ambulatory care entity.
Medicare further adds that teaching physicians submitting claims under this exception:

• May not supervise more than four residents at any given time.
• Must be immediately available.
• May not have other responsibilities (including the supervision of other personnel) at the time the resident provided services.
• Must have primary medical responsibility for patients cared for by the residents.
• Must ensure the care provided was reasonable and necessary.
• Must review the care provided by the resident during or immediately after each visit. Claims must include a review of the patient’s medical history, the resident’s findings on physical examination, the patient’s diagnosis and treatment plan.
• Must document the extent of his or her own participation in the review and direction of the services furnished to each patient. Patients under this exception should consider the center to be their primary location for health care services. Residents must be expected to provide care to the same group of established patients during their residency training. The types of services furnished by residents under this exception include:
• Acute care for undifferentiated problems or chronic care for ongoing conditions.
• Coordination of care furnished by other physicians and providers.
• Comprehensive care not limited by organ system or diagnosis.

Resources: Medicare Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners, Section 100.
Patricia Champion, CPC, is an approved PMCC instructor and a member of the AAPC’s National Advisory Board.

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