Synopsis

A Synopsis of the New Medicare Rules On Payment
for Teaching Physicians

Introduction
The General Rule
Application of the General Rule
Documentation

The following information is a summary of the basic requirements of the final Medicare rule on payment for the services of a "teaching physician" when a resident or clinical fellow is involved in a patient's care. This information should assist a teaching physician in understanding the standards. In order to assure full compliance, however, teaching physicians should consult the full text of the regulatory standards set forth at 42 C.F.R. § 415.150. Any clinical faculty member that involves a resident during the management of their patients is considered a teaching physician. Please note that if Georgia's Medicaid program adopts Medicare rules for provider reimbursement, then the rules described here will also apply for physician services to Medicaid enrollees.

In 1969 HCFA issued IL-372, setting forth specific conditions that attending physicians in teaching settings had to meet to be considered teaching physicians and, thus qualify to charge the carrier for services involving residents. The rule however, has not been applied uniformly by all Medicare carriers. On July 26, 1995 HCFA proposed a rule to revise and replace IL-372 criteria. The final rule was published December 8, 1995 and made effective July 1, 1996. It:

Eliminates the attending physician requirements of IL 372 and instead allows any teaching physician to bill a unit of service.
Requires that for a bill to be submitted, the teaching physician must be physically present except under limited circumstances.
Specifies the documentation requirements necessary for a teaching physician to bill for a service when a resident is involved.

The General Rule

When a resident participates in a service furnished in a teaching setting, a physician fee schedule payment (Part B) is made only if a teaching physician is present to perform or observe the resident perform the key portion of that service or procedures for which payment is sought.

HCFA has provided guidance on what is considered the key portion of a service such as surgery and procedures performed through an endoscope.

Application of the General Rule

Evaluation and Management Services

Unless the teaching physician qualifies for the out-patient exception, the physician must be present during the portion of the service that determines the level of the service billed. Teaching physicians should refer to the CPT guidelines for E/M services.

Surgery

The teaching physician must be present during all critical portions of the procedure. HCFA allows the teaching physician to define the key portion of each procedure. Presence is not required during opening and closing of the procedure.

The teaching physician must be immediately available during the entire service,e.g., in or near the operating room. Other activities, such as records review, may be performed if they will allow the physician to return to the patient if necessary. However, activities such as outpatient care are precluded.

Scopes

The teaching physician must be present during the entire viewing portion of the scope. Documentation must support the physical presence of the teaching physician.

Radiology and Diagnostic Tests

Payment for radiology and diagnostic tests is made only if the teaching physician:

Personally performs the service, or
Reviews the film and the resident's interpretation with the resident.

Psychiatry

The teaching physician can fulfill the physical presence requirements by concurrent observation via a two-way mirror or video camera for the entire session, followed by immediate consultation with the resident. Review after the service is over is not sufficient for the teaching physician to submit a bill to Medicare. The teaching physician must be present during the entire therapy session in order to bill for the service.

Outpatient Exception Criteria - "Medicare" Applies Only to Levels 1, 2 and 3 E/M Services in Primary Care

HCFA has created an outpatient exception to the physical presence requirement for levels 1, 2, 3 of evaluation/management services for primary care specialties. To qualify for the exception, all of the following criteria must be met:

The service must be furnished in an outpatient center or other ambulatory entity.
The resident must have completed 6 months of training.
The teaching physician can direct no more than four residents at any one time.
The patients must be an identifiable group who consider the center as their source of continuing health care.
Residents must provide comprehensive care in a continuity setting and be trained in all organ system and disease processes.

Documentation

Evaluation and Management (E/M) Services

For any E/M service, the level selected is based on the Documentation Guidelines for Evaluation and Management Services developed by the AMA and HCFA.

The teaching physician must personally document in the medical records his/her presence and participation in the service at the time the service is furnished. This documentation must include:

A notation that the teaching physician was present during the resident's history and examination of the patient; or
A notation that the teaching physician personally examined the patient and discussed the history, examination and medical-decision making with the resident before the end of the patient encounter.

In addition, the teaching physician must document his involvement during the key portion of the history, exam or decision-making. If the resident has documented the teaching physicians presence, the teaching physicians must simply note his presence during the key portion. It is vital that residents be trained in efficient documentation since their notes must contain appropriate elements according to the guidelines.

The key elements of history, examination, and medical decision-making are defined as those elements that, in the judgement of the teaching physician, best summarize: a) the relevant history, physical examination, and prior diagnostic tests; b) assessment, clinical impression, or diagnosis; and c) the plan for care.

This is an everchanging area. As such, if you have any questions regarding the appropriate applicable guidelines, please contact the compliance officer or legal counsel.

Refer to the MMA Compliance Plan Manual for detailed information regarding IL 372, Federal regulations and documentation. Copies of this manual and the July 1995 Documentation Guidelines have been distributed to each clinical department.

For more information:
Sarita Cathcart, MN, NP-C
Corporate Compliance Officer
Clinical Instructor / Family Medicine
Office of Clinical Affairs
Suite 125 E Piedmont Hall (404) 756 -1353

The material found on this web site is for informational purposes only. It does not constitute legal advice and is not guaranteed to be complete or up-to-date. In order to assure full compliance with both federal and state law, regulations, or policies and interpretation of same, users of this web site should consult legal counsel.