Medicare Primary Care Center Exception Update
Clarify the rules, and understand documentation requirements and limitations when reporting services.
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 revised and clarified the rule. Let’s assess the current regulations to see how they affect coding and billing in your medical practice.
Generally, to bill Medicare Part B for services involving residents, the teaching physician must personally perform the service, or at least be physically present during the critical or key portions of the service. Only specified services performed by residents under a “primary care exception” (within an approved Graduate Medical Education Program) may be billed to Medicare Part B under the teaching physician’s provider number without the teaching physician there to perform the service.
The primary care center 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. Residency programs most likely to qualify for the exception include family practice, general internal medicine, geriatrics, pediatrics, and obstetrics/gynecology.
Attest in Writing
For the exception to apply, the center must attest in writing to the Medicare administrative contractor (MAC) that the following conditions have been met:
- The services are performed in a center 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.
- The residents involved have completed more than six months of a residency program.
- 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.
- The teaching physician has no other responsibilities at the time (including the supervision of other personnel) and manages responsibility for those patients seen by the residents.
- The patients seen are an identifiable group who consider the center to be the continuing source of their healthcare, and are cognizant that residents under the medical direction of teaching physicians furnish services. The residents follow the same group of patients throughout the course of their residency program.
Centers exercising the exception do not need to obtain prior approval, but they must maintain records demonstrating that they qualify for the exception.
Services Included Under the Exception
The range of services residents may furnish 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
Under the exception, residents may provide reasonable and necessary, low- to mid-level evaluation and management (E/M) services, and other specified services, without the presence of a teaching physician. Specific procedure codes that may be billed under the exception include:
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
For services other than those listed above, the general teaching physician policy applies.
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 that do not meet the requirements for an exception revert to the general teaching physician guidelines, and claims must include modifier GC This service has been performed in part by a resident under the direction of a teaching physician.
Follow 4-to-1 Ratio Rules
A teaching physician may not supervise more than four residents at any given time, and only residents who have completed more than six months of an approved GME program may furnish billable patient care without the teaching physician’s physical presence. Although residents with less than six months in an approved GME program do not qualify for the exception, they are counted among the four residents under supervision of the teaching physician. See the following chart for scenarios of how the 4:1 ratio affects billing.
To qualify for 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.
Good 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.
This is a good teaching physician note because it specifies that the teaching physician reviewed and discussed the history, physical examination, assessment, and plan provided by the resident, and it supports the teaching physician’s agreement with the plan of care for the patient.
Poor Teaching Physician Note Example
I have discussed the case with the resident.
This note is poor because it does not specify what was discussed with the resident, nor does it support the teaching physician’s direction of the services furnished to the patient.
“Guidelines for Teaching Physicians, Interns, and Residents,” www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf
Medicare Claims Processing Manual, Pub. 100-04, chapter 12, www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Maryann C. Palmeter, CPC, CENTC, CPCO, is director of physician billing compliance with the University of Florida Jacksonville Healthcare, Inc., where she provides professional direction and oversight to the billing compliance program of the University of Florida College of Medicine-Jacksonville. Her extensive experience in federal and state government payer billing and compliance regulations has been gained through executive level positions on both the physician billing and government contractor sides of the healthcare industry. Palmeter served as a National Advisory Board member from 2011-2013 and as secretary from 2013-2015. She was named AAPC’s 2010 “Member of the Year” and is a member of the Jacksonville, Fla., local chapter.