Be Aware of Your Payers’ Teaching Physician Guidelines
Dig in to “Test Your Knowledge of Teaching Physician Guidelines” for clarification.
Because Medicare is a national program, one might expect the billing and documentation rules to be the same in all 50 states. As healthcare business professionals, however, we know this is not the case. In the article “Test Your Knowledge of Teaching Physician Guidelines” (September 2015), we tested your knowledge of teaching physician guidelines. Now, let’s expand your knowledge even further.
Evaluation and Management (E/M) Services
Relative to what the teaching physician must document to comply with the Centers for Medicare & Medicaid (CMS) rules for E/M services, a statement such as, “I saw and evaluated the patient. I agree with the resident’s documentation” may be acceptable in some states. But in other states, the Medicare administrative contractor (MAC) would consider this to be a generic attestation, and require the teaching physician to personalize the documentation to the specific patient and the teaching physician’s role in the plan.
CMS does not require the teaching physician to see every Medicare patient. Based on the experience level of the resident, it’s not always necessary for the teaching physician to render services when the resident has already seen the patient. Some MACs require more than a generic attestation (“macro” or “smart phrase”) to support the teaching physician’s services. The statement, “I saw and evaluated the patient with the resident” is an acceptable smart phrase for the teaching physician to use in the electronic health record, if the teaching physician adds patient-specific details of the plan.
The level of E/M billed should reflect what was medically necessary for the patient, and not necessarily the level required and documented for teaching purposes.
Given that, the 2nd, 4th, 5th, and 15th examples in “Test Your Knowledge of Teaching Physician Guidelines” may need to include a personalized teaching physician note, depending on your MAC.
Regarding medical students, a teaching physician may only use the medical student’s review of systems and past family social history. A teaching physician may not use a teaching physician attestation when working with a medical student.
There are specific requirements the teaching physician must meet when billing for critical care. Key elements that must be documented include:
- The time the teaching physician spent providing critical care;
- That the patient was critically ill during the time the teaching physician saw the patient;
- What made the patient critically ill; and
- The nature of the treatment and management provided by the teaching physician.
The medical review criteria are the same for a teaching physician as for all other physicians (see CMS Transmittal 1548).
CPT® explains that the level of certain E/M services may be selected using time as the determining factor if over 50 percent of the total visit time was spent in counseling or coordinating care. Note, however, that some MACs (and even private insurers) may no longer accept documentation of a “50 percent” statement and total visit time. Some payers require two specific times to be documented in the medical record: the time spent counseling and the total time of the visit. As a best practice, providers should include both times.
“Test Your Knowledge of Teaching Physician Guidelines” provided an example (No. 10) in which, “The general surgery resident documents the hernia repair and states the attending physician was present for the entire surgery. The attending co-signs the note,” and concludes that this is acceptable documentation because “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.” Note that the teaching surgeon must also sign either the operative note or her or his own progress note. Unless the surgeon’s signature is present, outside auditors may consider the service to be an overpayment.
For overlapping surgeries (e.g., “Test Your Knowledge of Teaching Physician Guidelines,” No. 12), the teaching surgeon must indicate the qualified surgeon who was available to immediately assist the resident. Medicare Carriers Manual section 100.1.2 (revision 1859) states, “When a teaching physician is not present during the non-critical or non-key portions of the procedure and is participating in another surgical procedure, he or she must arrange for another qualified surgeon to immediately assist the resident in the other case should the need arise.”
“Test Your Knowledge of Teaching Physician Guidelines” No. 13 provided a scenario in which a family medicine resident sees an established patient for follow-up of his hypertension and to receive a knee injection to relieve pain cause by osteoarthritis. The resident documents the encounter, including the injection administration. The attending documents, “I saw and examined the patient. I agree with the resident’s note.”
In this case, you may be able to bill the visit if your MAC doesn’t require a personalized teaching physician note; however, you cannot bill the injection because the teaching physician does not state that he or she was present for the injection.
Judy Harris-Guay, CPC, has been the director of medical billing and research compliance at Yale University School of Medicine for 18 years. She is the author of “Ready, Set, Comply” (first edition) and owner of the Compliance Audit Tracking System, LLC. Harris-Guay is a member of the New Haven, Conn., local chapter.