Thursday, August 23, 2012

Training our Residents, Teaching Physician, Interns and Residents - Coding it correctly

I put this article out for HCPRO - and wanted to also share some of my Insight of this topic with you too...   Teaching physicians bear a huge responsibility in getting our residents, medical students, and interns trained "on the job".  It's one thing to do it in a classroom setting, but quite another to be "on the job".   The coding for these services is very tricky.  CMS has put out a great guideline resource, but I've tried to dissect this out to make it easier for you (as the coder/biller/manager) to figure out what needs to happen to get reimbursed for the services provided...  ENJOY!!  and HAPPY CODING!

Clearing up the confusion:  Coding Tips for Teaching Physicians, Interns, Residents and Students

There are many challenges to coding for Teaching physicians, interns, residents and students.  Medicare (CMS = Centers of Medicare and Medicaid Services) has very specific rules and regulations as to what they will and will not pay for when services are provided by an intern, resident or a student.   Coding is only one piece of the reimbursement puzzle when it comes to these issues.  The first area that we need to outline is the definition of “who” is the provider of care, and “who” is the oversight /proctoring/mentoring provider for the intern, resident and/or student. 

The guidelines provided by CMS may or may not be followed by independent 3rd party insurance payers.  It is wise to contact those payers if unsure if they will recognize any billing or payment for services provided by an intern, resident and/or student for their subscribers

Definitions we need to know: (As per CMS)

Teaching Physician: A physician, other than an intern or resident, who involves residents in the care of his or her patients. Generally, the teaching physician must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service in order for the service to be payable under the Medical Physician Fee Schedule.

Intern or Resident: An individual who participates in an approved Graduate Medical Education (GME) Program or a physician who is authorized to practice only in a hospital setting (e.g., has a temporary or restricted license or is an unlicensed graduate of a foreign medical school).    Also included in this definition are interns, residents, and fellows in GME Programs recognized as approved for purposes of direct GME and Indirect Medical Education (IME) payments made by Fiscal Intermediaries or A/B Medicare Administrative Contractors, receiving a staff or faculty appointment, participating in a fellowship, or whether a hospital includes the physician in its full-time equivalency count of residents does not by itself alter the status of “resident.”.

Student:  An individual who participates in an accredited educational program (e.g., medical school) that is not an approved Graduate Medical Education Program and is not considered an intern or resident. Medicare does not pay for any services furnished by a student. Medical students are not licensed physicians; they are students. 

Now that we have ascertained what the roles are in a teaching physician setting, the next thing we have to do, is determine the service that is being provided, and if that service can be reimbursed by a 3rd party payer.

According to CMS (Medicare services)  Medicare will pay for medical or surgical services if the service was provided by a licensed physician (face to face) and that provider of the service is not a resident.  In some of Medicare’s information the term “physically present” will be noted.  This simply means the teaching physician and the resident physician are together with the patient in the same room or exam area. 

CMS (Medicare Services) will pay for services provided by a resident if a “teaching physician is present during critical or key portions of the service or procedure.   The issue here is CMS (Medicare) does not elaboarate with their guidelines of what they consider “critical or key portions” of the service being provided by the resident.  Documentation by both the resident and the teaching physician is critical, in the absence of guidelines as to what CMS considers “creitical or key” in regard to the service being provided.

CMS (Medicare) requires strict adherence to their guidelines, so payment can be made to the provider of the service.  For 3rd party payers, most will default to what CMS has outlined.  However, some 3rd party insurers have their own guidelines, and may or may not pay when a resident has seen the patient and provided services. 

Documentation Criteria and guidance for the teaching physician:

If your provider is operating in the capacity of a ‘teaching physician” or “oversight physician, these are the nuts and bolts of what needs to be documented.

§    As the Teaching Physician your participation in the review of the history/chief complaint of the patient as taken by the Intern/Resident and/or student and verified by you.

§    As the Teaching Physician Your participation in the management of the patient to include the examination and medical decision making.

§    As the Teaching Physician, you were physically present during the “critical or key” portions of the service/procedure provided by the Intern/Resident and/or student.

§    The combined entries from BOTH you and the Intern/Resident and/or student will be needed to support the medical necessity of the care of the patient, and to be billed to Medicare or another 3rd party payer.

§    Documentation of a service or procedure provided by the resident only – with a notation stating the Teaching Physician’s presence and participation IS NOT sufficient to bill CMS(Medicare) for  that service. 

§    It must be clearly documented and identifiable by BOTH the Teaching Physician and the Intern/Resident and/or student as to what portions of the services were performed by each provider of care.

Unacceptable documentation examples by a Teaching Physician include those such as below, that are followed with a countersignature.   A Countersignature by itself is insufficient for documentation purposes.

§    “I saw and evaluated the patient,
§    “I reviewed the residents note and agree with the plan”
§    “agree with the above……” 
§    “patient seen and evaluated…….”
§    “discussed with Resident and agree with plan……….”

Minimally acceptable documentation (provided below from CMS) outlines what needs to be included when billing for services provided by the Intern/Resident with a Teaching Physician
Examples of minimally acceptable documentation include:
§    "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care."
"I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."
"I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs

Both the Resident/Intern and the Teaching Physician must have separately identifiable documentation, and clarity regarding their physical attendance (face to face) with the patient.

If the service that was provided is a time-based code such as code 99238 or 99239, the teaching physician must be present for the entire period of time specified by the code.  For code 99238 it states the discharge is 30 minutes or less, code 99239 states 30 minutes or more.  With code 99239, 30 minutes or more does not specifically note “face to face” time, by CPT,  so as long as the documentation by the teaching physician details that the time took more than 30 minutes it would be sufficient.

In the case of critical care time, where code 99291 states it can be used for the first 30-74 minutes, this time must be face to face time with the patient, and the teaching physician must be present for the entire period of time for which you are billing for.  The same holds true for E&M codes.  If the provider wants to bill for a time-based E&M code, then 50% of the total time spent must be face to face with the patient, documenting that the 50% was spent in counseling and coordination of care with the patient.

When coding and billing for teaching physicians, CMS requires the use of modifier “GC”, or the use of modifier “GE”  When the CMS 1500 form is filled out these two modifiers are required by Medicare to provide information in respect of teaching physician service,  The use of the modifier, does not increase or decrease the payment to the teaching physician.  If you are billing for a 3rd party payer, they may or may not want either of these modifiers included.

Definition:  Modifier GC,   This service has been performed in part by a resident under the direction of a teaching physician.
Definition:  GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception

Originally posted to on August 22, 2012 
Informational references from 

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