Wiki Advice???

[lburgos31]

If our practice has privileges to perform consults in a Hospital setting, and a hospital employed resident completes the consult for our provider, when would it be ok to bill the Hospital Care?

Wouldn't our provider need to be employed by the Hospital (and be an attending) in order bill for that resident's consult, even if it was within their scope of practice?

What would our providers need to bill for residents that are not employed by our practice? Or can that not be done?

I've checked the CMS PA/NP Teaching Physicians Guide but it does not answer my questions.

Thanks.

 

[cgaston]

I believe Residents are assigned to a specific Attending Physician. The Attending will add an attestation to the Resident's note after having a face-to-face with the patient and then it is billed under the MD with a -GC modifier.

 

[lburgos31]

That's what I thought...but I need hard evidence to prove this to my manager and the docs...Our docs are usually never the attending. They are just the Consulting provider for Ortho within hospitals.

I believe Residents are assigned to a specific Attending Physician. The Attending will add an attestation to the Resident's note after having a face-to-face with the patient and then it is billed under the MD with a -GC modifier.

 

[AmandaBriggs]

This is directly from the MLN Booklet Guidelines for Teaching Physicians, Interns, and Residents:
Billing Requirements for Teaching Physicians
You must be identified as the teaching physician who involves residents in the care of your patients on claims. Claims must comply with requirements in the General Documentation Guidelines and E/M Documentation Guidelines sections. Claims must include the GC modifier, "This service has been performed in part by a resident under the direction of a teaching physician," for each service, unless the service is furnished under the primary care exception. When the GC modifier is included on a claim, you or another appropriate billing provider are certifying that you complied with these requirements.

And this:

When you bill E/M services, you must personally document at least all of the following:

1. That you performed the service or were physically present during the critical or key portions of the service furnished by the resident and
2. Your participation in the management of the patient

On medical review, the combined entries in the medical record by you and the resident constitute the documentation for the service and together must support the medical necessity of the service. Documentation by the resident of your presence and participation is not sufficient to establish such presence and participation.
https://www.cms.gov/Outreach-and-Ed.../Teaching-Physicians-Fact-Sheet-ICN006437.pdf

There are also requirements that must be met for ACGME (Accreditation Council for Graduate Medical Education). One of the stipulations is that there is a program letter of agreement between the program and each participating site that identifies the faculty who will assume educational and supervisory responsibilities for the residents. If you don't have one of these, then it is recommended that your provider perform and document the service. The billing is then submitted under your provider.

Hope this helps!

 

[Karen78]

we have orthopedic physicians that consult at our local teaching hospitals. As long as the physicians attest the consult done by the resident stating they were present for and physically saw and examined the patient themselves with the resident then they will be able to bill with the GC modifier. They must remember to attest or document that they were the supervising physician to the resident doing the consult or rounds. CMS has more information on the GC modifier usage.