Strict Rules Determine Payment for Resident Services
Published on Wed May 01, 2002
Because emergency medicine is ripe with learning opportunities, many medical students and residents complete part of their training in the ED. While beneficial to education, these relationships open the door for fraud and abuse when coders don't understand how to report care provided by these healthcare professionals.
"Simply put, most services rendered by a medical student cannot be billed" (see Classifications of Providers in box below), says Jim Blakeman, senior vice president for coding quality assurance with Healthcare Business Resources Inc., in Bala Cynwyd, Pa. The only services performed by a medical student that can be used in documentation are the history of the present illness (HPI) and review of systems (ROS), which can be recorded by any ancillary personnel and referenced by the physician as to review and agreement. "Care provided by residents is billed under the attending physician's name and provider identification number (PIN), but only if specific requirements are met."
Failing to meet these requirements results in serious consequences, he adds. Not long ago, Medicare expected noncompliant ED practices to repay only overages received. "Now they are also assessing fines and penalties. The largest penalty assessed was levied against the University of Pennsylvania several years ago and totaled $30 million. It's vital that physicians at teaching hospitals (PATH) and those who code their services understand the limitations," Blakeman says. Medicare has established the standard for reporting resident services, he says, with distinct rules for E/M services and other procedures or services. Other payers may not adopt these regulations. Medicaid, for instance, has not. "Because this varies greatly payer by payer," he notes, "ED physicians and coders should check with each insurer to determine the proper reporting methods." Medicare PATH Requirements for E/M According to Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City, attending physicians must meet two criteria in order to code residents' E/M services: "The attending or teaching physician must be physically present in the ED and must repeat important portions of each of the three key components of an E/M."
For instance, he says, a 9-year-old is brought into the ED with high fever, sore throat and vomiting. The resident examines the child, orders a strep test and diagnoses strep (034.0, Streptococcal sore throat). The attending also sees the patient. During face-to-face time with the patient, the teaching physician duplicates a segment of the history or HPI, examines the patient for the significant symptoms, and repeats a portion of the medical decision-making process.
"These activities must be clearly documented," Fick says. "The attending must leave a 'thumbprint' on the chart. He or she must clearly state, 'I was present' [...]
