Internal Medicine Coding Alert

Reader Questions:

Understand Teaching Physician Exceptions

Published on Sat Jan 01, 2005

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Question: My internist works at a teaching hospital, and I've heard about a "primary-care exception." What is it and how does it apply to my work?

Ohio Subscriber

Answer: The "primary-care exception" is a Medicare guideline that allows teaching physicians (TP) to bill for
E/M services that a resident provides, even though the TP didn't provide direct supervision. The exception applies only to primary-care practices, and you can report only E/M new patient codes 99201-99203 and established patient codes 99211-99213.

In addition, your office must be located in the outpatient department of a hospital or another ambulatory care entity, not a physician's office away from the center, and you cannot use the exception for services provided during a home visit, according to the Medicare Carriers Manual (MCM).

To meet Medicare's documentation requirements for reporting 99201-99203 and 99211-99213 under the exception, make sure you can satisfy the following MCM criteria, which state that your TP should:

supervise no more than four residents at a time and must be immediately available to help the resident;

maintain the primary medical responsibility for the patient's care;

ensure that the resident provides reasonable and necessary services; and

review the care provided by the resident during or immediately following each E/M visit. This review includes the patient's history, the resident's findings on physical examination, the diagnosis, and the treatment plan.

Further, the TP must document the extent of his participation in the review and direction of the patient care.

You should also attach modifier -GE (This service has been performed by a resident without the presence of a teaching physician under the primary-care exception) to all codes that you report under the exception.

- Answers for You Be the Coder and Reader Questions were answered by Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.