Learn Teaching Physician Guidelines
It can mean the difference between getting paid for services and a hospital eating the cost.
If you work in a teaching facility with residents, chances are you’ve had difficulty sorting through the Centers for Medicare & Medicaid Services (CMS) guidelines for proper billing of these services. Things start to make sense, however, if you break the guidelines down and focus on just the essential parts. Let’s give it a try.
Review Documentation Guidelines
To be reimbursed for evaluation and management (E/M) services, CMS requires that documentation from the teaching physician must establish:
- The teaching physician personally performed the service or was physically present when the resident performed the key portions of the service.
- The teaching physician participated in the management of the patient.
CMS is clear that a resident simply documenting the presence and participation of the teaching physician does not establish the presence and participation of the teaching physician.
Apply the Rules
Here is a scenario for the proper way to document an E/M service for a resident and teaching physician, per CMS:
The resident performs the elements required for an E/M service in the presence of, or jointly with, the teaching physician and the resident documents the service. In order to comply with CMS guidelines, the teaching physician must document his or her presence for the key portion(s) of the service, they must document their direct management of the patient and reference the resident’s note. The medical necessity of the encounter should be supported by both entries.
Here are two scenarios that CMS considers “minimally acceptable documentation” for teaching physician services:
- “I performed the history and exam of the patient and discussed the management with the resident. I have reviewed the resident’s note and agree with the findings and plan of care.”
- “I saw and evaluated the patient. I agree with the findings/plan of care in the resident’s note.”
- Here are three scenarios that CMS considers “unacceptable documentation” for teaching physician services:
- “Agree with above,” followed by the teaching physician’s signature
- “Rounded, reviewed, agree,” followed by the teaching physician’s signature
- “Discussed with resident. Agree,” followed by the teaching physician’s signature
- These scenarios are not acceptable because CMS rules state that the teaching physician personally must document their presence and participation in the management of the patient.
Call on Modifier GC for Billing
When billing teaching physician services to Medicare, append modifier GC This service has been performed in part by a resident under the direction of a teaching physician to the E/M service code.
For example, a resident sees a patient with the teaching physician for an initial hospital visit. A comprehensive history and exam are performed and the medical decision-making is of moderate complexity. The resident documents the note jointly with the teaching physician. The teaching physician notes her presence when the resident performed the key components of the visit, references the resident’s note, and notes her (the teaching physician’s) direct management of the patient.
This encounter would be billed 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity-GC.
Dawson Ballard, Jr., CPC, CEMC, CPMA, CPC-P, CCS-P, is an AAPC Fellow, a coder, and a member of the Overland Park, Kan., local chapter.