Primary Care Exception in Brief
Under the “primary care exception,” a medical resident may perform (and bill for) limited, specific evaluation and management services without the presence of a teaching physician. Here’s what you need to know when reporting these resident services.
When the Primary Care Exception Applies
Ordinarily, services furnished by medical residents are excluded from Medicare payment because Medicare already reimburses teaching hospitals for resident services.Per the Centers for Medicare & Medicaid Services (CMS) MLN Booklet, “Guidelines for Teaching Physicians, Interns, and Residents,” an exception may apply when the following conditions are met and have been attested to, in writing:
- The services were furnished in a primary care center located in the outpatient department of a hospital or another ambulatory care entity where the time spent by residents in patient care activities is included in determining DGME payments to a teaching hospital. This requirement is not met when the resident is assigned to a physician’s office away from the primary care center or when he or she makes home visits. The non-hospital entity should verify with the MAC that it meets the requirements of a written agreement between the hospital and the entity.
- Residents who furnish billable patient care without your physical presence have completed more than six months of an approved residency program.
- The supervising provider must not supervise more than four residents at any given time, and must direct the care from such proximity as to constitute immediate availability. Residents who have completed less than six months in an approved GME Residency Program may be included in the mix of four residents under supervision; however, the supervising provider must be physically present for the critical or key portions of these services.
- The supervising provider must:
- Have no other responsibilities, including the supervision of other personnel, at the time services are furnished by residents.
- Have primary medical responsibility for patients cared for by residents. Ensure that the care furnished is reasonable and necessary.
- Review the care furnished by residents during, or immediately after, each visit. This must include a review of the patient’s medical history and diagnosis, the resident’s findings on physical examination, and the treatment plan (for example, record of tests and therapies).
- Document the extent of your participation in the review and direction of the services furnished to each patient.
- The primary care center is considered the patient’s primary location for health care services. Residents must be expected to generally furnish care to the same group of established patients during their residency training.
Only select services may be reported under the primary care exception, to include new patient codes 99201-99203; established patient codes 99211-99213, and; Medicare service 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, and G0439 … subsequent visit.
As explained in the “Guidelines…” MLN Booklet, the range of services furnished by residents 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
Documenting Primary Care Exception Services
The teaching physician must document the extent of his or her participation in the review and direction of the services furnished to each patient. Documentation to support the services of the teaching physician may be dictated and typed, hand-written, or computer-generated.
Append Modifiers GC and GE, as Needed
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 primary care exception.By contrast, when a resident is involved with care but that care does not meet the primary care exception, the teaching physician appends modifier GC This service has been performed in part by a resident under the direction of a teaching physician to the procedure codes.
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