Test Your Knowledge of Teaching Physician Guidelines
By Erin Andersen, CPC, CHC
Teaching hospitals receive federal money to train residents. When teaching physicians are involved in a patient’s care and meet certain criteria, their documentation (combined with the resident’s) may be used to bill a professional fee to Medicare Part B, Medicaid, and insurance companies. Teaching physician rules are Medicare rules, but most insurance companies follow them, as well.
Let’s go through both common and unusual scenarios to test your knowledge of Medicare’s teaching physician rules, which may be found in the Medicare Claims Processing Manual, chapter 12, section 100, and in MLN Matters® “Guidelines for Teaching Physicians, Interns, and Residents.”
Disclaimer: This test is a fun exercise for those who are in love with the craft of medical coding. No continuing education units (CEUs) will be awarded for correct responses.
Evaluation and Management (E/M)
1. Which statement(s) meet Medicare’s teaching physician rules?
A. I saw and evaluated the patient. I agree with the resident’s documentation.
B. The patient was evaluated. Please see resident’s note.
C. My exam shows the patient to be alert and oriented, RR, and no hepatosplenomegaly. Encourage aggressive albuterol use with beginning of colds, coughing, and wheezing. Start 2-3 times per day and increase to every four hours with worsening symptoms.
The answer is A. In the list of acceptable statements in the guidelines, there are four common traits among them:
1. A personal pronoun;
2. The teaching physician saw the patient;
3. The teaching physician reviewed the resident’s documentation; and
4. The teaching physician either agrees with the resident’s documentation or notes exceptions.
Statement “A” meets all of these. “B” does not have a pronoun to indicate the teaching physician personally saw the patient, nor is there evidence the teaching physician reviewed or agrees with the resident’s note. “C” shows evidence the teaching physician saw the patient, but there is no documentation to show the teaching physician reviewed or agrees with the resident’s note. For “C,” the teaching physician’s minimal documentation could be used by itself to bill a low-level E/M code.
2. A patient is admitted to the hospital at 9 p.m. on May 1, 2015. The on-call resident examines the patient, initiates treatment, and then writes an admit note. The next morning, the attending physician sees the patient on rounds and writes, “I saw and examined the patient. No changes. I agree with the resident’s note.”
What can be billed?
A. An initial inpatient code for the May 1 date of service
B. An initial inpatient code for the May 2 date of service
C. Nothing, the physician cannot use the resident’s note from the previous day.
The answer is B. Because the attending physician did not see the patient on May 1, the initial inpatient code cannot be billed for that day, but the resident’s documentation to can be used to bill for May 2. The guidelines describe a similar situation in which it’s allowed for an attending physician to use the resident’s note from the previous calendar day.
3. An oncologist sees an established patient for a scheduled outpatient hospital visit. The patient’s condition has worsened to the point that the patient must be admitted. The oncologist places the admit order, as well as other orders for tests and treatment initiation. The oncologist does not see the patient in the hospital later the same day.
What can be billed?
A. An initial inpatient code using the outpatient visit note
B. An established outpatient code
C. Either one, but not both
The answer is C. All clinical documentation from the same provider group on the same day of service may be used to support the initial inpatient level of service, even if the billing provider did not see the patient after admission on the same day. It would also be appropriate for the oncologist to bill an established outpatient code (but not both codes for the same day).
4. Building off the scenario above: Another resident sees the patient on rounds with the attending physician on May 2 and writes a brief, subsequent inpatient note. The same attestation from above is documented on the resident’s note from May 2.
What can be billed?
A. An initial inpatient code using both residents’ notes
B. An initial inpatient code using the May 1 resident’s note
C. A subsequent inpatient code using the May 2 resident’s note
The answer is C. The attending physician’s note does not specify that she read and agrees with the May 1 resident’s note. Without documentation of this action, the May 1 resident’s note cannot be used. Although it’s possible to bill an initial inpatient code using the May 2 resident’s note, it likely does not contain enough elements of history, and perhaps exam, to meet the requirements of 99221. In that case, you could bill an unlisted E/M code or a subsequent inpatient code.
5. Interventional radiologist Dr. Jones sees a patient for an inpatient subsequent visit and writes a note. An attending interventional radiologist and a vascular surgeon both see the patient. Each writes, “I saw and evaluated the patient. I agree with Dr. Jones’ note.”
Can both attending physicians use the same resident’s note to support their level of service?
B. No, only one can.
C. No, only the interventional radiology attending can.
The answer is B. It would be double-dipping to use the work of the resident twice. The guidelines do not specify that an attending cannot use a resident’s note from another specialty; however, it’s implied that the attending physician is acting in a teaching capacity towards the resident and not merely using the resident’s note to avoid having to personally document the encounter. In this scenario, only one attending may use the resident’s note. Typically, that would be the interventional radiologist attending, since he or she would likely be acting as the teaching physician, in this case.
6. For an established outpatient visit, an internal medicine attending physician documents, “I was present the entire time with the medical student. I repeated portions of the history and exam. I agree with the student’s excellent note.”
Can the attending physician use any portion of the medical student’s note to support his level of service?
A. Yes, he was there the entire time and performed the critical aspects of the E/M service.
B. No, Medicare does not pay for any services performed by a medical student even if the attending was present.
C. Yes, the past medical, family, social history, and review of systems may be used to support the attending physician’s level of service, but the attending physician did not document enough of the other elements to support billing an E/M.
The answer is C. It’s arguable whether it would be appropriate to bill 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. Even if the attending physician was present the entire time with a medical student, he or she needs to personally document the history of present illness, exam, and medical decision-making (MDM).
It would be risky for a medical student to use the same template as a resident or attending physician. It may appear the resident or attending physician copied the medical student’s documentation to claim it as his or her own.
7. A resident writes an excellent note about a newly admitted, critically ill patient. The attending physician documents:
CC time: 35 min. I saw and examined the critically ill patient. I agree with the resident’s note.
What can be billed?
A. An initial inpatient code
C. Either code, but not both
The answer is A. The guidelines state that the attending physician must document the critical nature of the patient’s illness and the care that he or she specifically provided. Merely stating the patient is critically ill does not describe the condition, nor does the statement demonstrate the attending physician’s level of involvement in providing critical care.
The time statement should indicate that it was the attending physician’s time only by using a personal pronoun. Without the pronoun, you might assume the time was both the resident’s and the attending physician’s time, combined. When billing based on time, only the attending physician’s time may be used to support the billed code.
8. Both a resident and an attending physician see an established patient in the clinic. The resident documents the encounter and includes the following time statement, “We spent 45 minutes face-to-face with the patient. Over 50 percent was spent counseling the patient about her diabetes and weight management.” The attending physician documents, “I examined the patient with the resident. I agree with her note.”
Can 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity be billed based on time?
The answer is C. Query the resident and/or the attending physician to see if the attending physician was present the entire time (all 45 minutes). If so, one of them (ideally the attending physician) should clarify the time statement to clarify that the attending physician was present for all 45 minutes. If the time documented included time when the attending physician was not present, the note should be billed based on the elements of history, exam, and MDM.
9. A dermatology resident uses liquid nitrogen to burn off two warts on the patient’s hand and documents the service. Her attending physician adds his teaching statement, “I was present for the critical portions.”
Is this sufficient to bill for the wart destruction?
The answer is B. The guidelines say the teaching physician must be present the entire time for procedures taking less than five minutes. For procedures taking longer than five minutes, the teaching physician need only be present for the critical portions of the procedure. It’s unlikely the wart destruction took more than five minutes; therefore, the teaching physician’s level of involvement is not sufficient to bill for the service.
10. The general surgery resident documents the hernia repair and states the attending physician was present for the entire surgery and co-signs the note.
Is this acceptable to bill the hernia repair?
The answer is A. The guidelines state that if the teaching physician is present the entire time, a resident or operating room nurse can document the entire encounter, including the teaching physician’s presence.
11. The resident documents a blepharoplasty and the following: “Dr. Smith was present for the critical portions.” The ophthalmologist documents, “I was present the entire time.”
Is this acceptable?
The answer is B. The statements are contradictory. The documentation needs to be corrected to reflect what actually happened.
12. The neurosurgeon was present for the critical portions of three surgeries this morning. Surgery 1 occurred in building A from 8:00 – 10:00 a.m. Surgery 2 occurred in the room next to surgery 1, from 9:30 – 11:30 a.m. Surgery 3 occurred across campus in building C, from 10:00 a.m. – 12:00 p.m. The residents documented the encounters and the neurosurgeon added the following presence statement to each, “I was present and/or performed the critical portions.”
Has the surgeon met the presence requirements to bill each surgery?
A. Yes, there were only two overlapping surgeries, as per the guidelines.
B. No, the surgeon was not immediately available for surgery 3.
C. Yes, the surgeon can teleport.
The answer is B. Surgery 1 and Surgery 3 did not overlap. The guidelines allow for a maximum of two overlapping surgeries, but the surgeon must be immediately available to attend the other surgery. Check to see how your Medicare carrier defines “immediately available;” it’s commonly understood to mean “without delay.” By that definition, the surgeon was not immediately available if he was across campus in another building.
Secondly, the surgeon’s presence statement, “present and/or performed,” is unclear. Although this will not prevent any of the surgeries from being billed, the surgeon should state clearly whether he performed a given surgery, or merely present for it.
Lastly, if the surgeon was performing the critical aspects of one of the overlapping surgeries, there is a question of whether the surgeon could be immediately available for the other surgery. Would the surgeon be able to disengage himself from the act of performing surgery 1 and get to surgery 2 without delay, even if it was in the next room?
13. A family medicine resident sees an established patient for follow-up of his hypertension, and to receive an injection in his knee to relieve the pain caused by osteoarthritis. The resident documents the encounter, which includes giving the patient the injection. The attending physician documents, “I saw and examined the patient. I agree with the resident’s note.”
Is this sufficient to bill both an established outpatient visit code and the injection?
B. No, the injection was scheduled so you can’t bill the visit.
C. No, we do not know if the teaching physician was present for the injection.
The answer is C. The injection was scheduled, but the E/M portion of the visit was for hypertension and not for knee pain.
14. A cardiothoracic surgeon documents a coronary artery bypass graft (CABG) and states he was present for the critical portions.
Is this acceptable?
A. Technically, yes; philosophically, no
The answer is A. According to the guidelines, this meets the letter of the law. But how can the surgeon document steps for which he wasn’t present? It either means he is assuming the normal course of events occurred, documenting what the resident told him happened, or his presence statement is incorrect.
15. The otolaryngologist documents she was present for the critical portions of the laryngoscope performed by the resident.
Is this acceptable?
A. Yes, the scope can be billed.
B. No, the otolaryngologist must be present the entire time for the scope or perform it again herself.
The answer is B. The attending otolaryngologist must be present from the insertion to the removal of the scope or re-scope of the patient.
16. The pulmonology resident documents the bronchoscopy and states the pulmonologist was present the entire time. Is this acceptable?
The answer is B. The guidelines allow for a resident or operating room nurse to document a surgery when the attending physician is present the entire time. Because this is a nonsurgical scope, it does not fall under the same guidelines — but your Medicare carrier may find this acceptable.
17. The radiologist reviews the resident’s interpretation of an X-ray and documents that he agrees with the resident’s note. Is this sufficient to bill for the interpretation?
The answer is B. The attending radiologist must review the film himself to know whether he agrees with the resident’s interpretation.
How Did You Do?
Did you get all 17 questions correct? Reading the guidelines carefully, paying attention to the verbiage used in the medical records, and educating teaching physicians about the rules are key to billing appropriately for services involving residents and students.
Erin Andersen, CPC, CHC, is an assistant integrity officer at Oregon Health & Science University in Portland, Ore. She has worked in coding and compliance since 2003, performing chart audits and investigations as well as educating providers, coders, and staff on coding and billing. Andersen is an active member of the Rose City Local Chapter and has served on the AAPC Chapter Association board of directors.
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