Health Information Management

Coding, billing, and documentation tips for teaching physicians, interns, residents, and students

JustCoding News: Outpatient, August 22, 2012

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by Lori-Lynne A. Webb, CPC, COBGC, CCS-P, CCP, CHDA

Coders face many challenges when coding for services provided by teaching physicians, interns, residents, and students. Medicare has specific rules and regulations surrounding what services it will pay for when an intern, resident or a student provides services.
 
But coding is only one piece of the reimbursement puzzle. First it’s important to define who is providing care and who is providing the oversight/proctoring/mentoring for the intern, resident, or student.
 
Third-party payers may or may not follow CMS’ guidelines. To confirm, contact those payers to make sure they will recognize any billing for services provided by an intern, resident, or student.
 
CMS definitions
 
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 care  during the entire encounter in order for the service to be payable under the Medicare 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). This definition includes interns, residents, and fellows in GME Programs approved for direct GME and Indirect Medical Education (IME) payments by fiscal intermediary (FI)/Medicare administrative contractor (MAC).
 
Student: An individual who participates in an accredited educational program (e.g., medical school) that is not an approved GME 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.
 
Payment for services
 
Now that you know the roles of individuals in a teaching physician setting, next you must determine what service is being provided, and if your facility will be reimbursed for that service.
 
According to CMS, Medicare will pay for medical or surgical services provided by a licensed physician in a teaching setting.
 
CMS will pay for services provided by a resident if a “teaching physician is present during critical or key portions of the service or procedure.” 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.
 
Unfortunately CMS does not elaborate on what it considers “critical or key portions” of the service the resident provides. The teaching provider must decide what it considers critical or key portions of the service provided. In the absence of more definitive guidelines, it is vital that both the resident and teaching physician document the services they provide. That way both providers can show when the supervising physician was present and what the supervising physician believed to be the key or critical portions of the service.
 
CMS requires strict adherence to it guidelines in order for it to reimburse the provider of the service. Most third-party payers will default to CMS’ guidelines. However, some third-party insurers have their own guidelines, and may or may not pay when a resident has seen the patient and provided services. Someone in your organization may need to call that third-party payer to ensure compliance with its policies, especially if you are contractually bound to that payer.
 
 
Documentation criteria and guidance for the teaching physician
 
If your provider is serving as a teaching physician or oversight physician, he or she must clearly document:
 
  • Participation in the review of the history/chief complaint of the patient as taken by the intern/resident and/or student
  • Participation in the management of the patient to include the examination and medical decision-making  
  • Physical presence during the “critical or key” portions of the service/procedure provided by the intern/resident and/or student

If a surgical procedure is performed, the teaching physician must be present during all critical and key portions of the procedure, and must be immediately available to step in and take over care if needed. Anyone involved in the surgical area, such as a surgical assistant, nurse, or staff member assigned as a scribe can document the information. If the procedure takes fewer than five minutes to perform, this is considered a minor procedure, and the teaching physician must be present during the entire procedure.

 
If a radiological or pathological test is performed, the resident may perform that diagnostic testing, but again the teaching physician will need to verify that the test was medically necessary. The resident physician must document and sign the interpretation. The teaching physician must also indicate that he or she reviewed the interpretation and note whether he or she agrees or disagrees with the findings. The teaching physician does not have to be present during the testing or for pathology or laboratory interpretation by the resident. Teaching physicians only need to carefully review and document their findings in addition to the residents’ findings.

 
Coders and billers will need the combined entries from the teaching physician and the intern/resident and/or student to support the medical necessity of the care of the patient, and to bill Medicare or another third-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 for that service.

 
The documentation must clearly indicate which portions of the service were provided by the teaching physician, intern, resident, or student.
 
Unacceptable documentation
Unacceptable documentation by a teaching physician includes the following examples with a countersignature:

 
  • “I saw and evaluated the patient”
  • “I reviewed the resident’s note and agree with the plan”
  • “Agree with the above……”
  • "Patient seen and evaluated…….”
  • “Discussed with resident and agree with plan……….”
 
A countersignature by itself is insufficient for both documentation and billing purposes.
 
According to CMS, at minimum, the following documentation must be included when billing for services provided by the intern/resident with a teaching physician:
 
  • "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, face-to-face attendance with the patient.
 
Coding and billing for services provided by resident/intern and teaching physician
If the service that was provided is a time-based code, such as code 99238 (hospital day discharge management, 30 minutes or less) or 99239 (hospital day discharge management, more than 30 minutes), the teaching physician must be present for the entire period of time specified by the code.
 
With code 99239, 30 minutes or more does not specifically note “face-to-face” time. As long as the documentation by the teaching physician details that the time took more than 30 minutes, it should be sufficient for billing purposes.
 
In the case of critical care time, in order to report code 99291 (critical care, evaluation and management of the critically ill or critically injured patients; first 30-74 minutes), this time must be face-to-face with the patient, and the teaching physician must be present for the entire period of time.
 
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 and the provider must document that he or she spent that 50% counseling and coordinating care with the patient.
 
When coding and billing for teaching physicians, CMS requires the use of modifier -GC (this service has been performed in part by a resident under the direction of a teaching physician), or -GE (this service has been performed by a resident without the presence of a teaching physician under the primary care exception).
 
Medicare requires these two modifiers on the CMS 1500 claim form 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 third-party payer, that payer may or may not want either of these modifiers included.
 
Editor’s note: Webb is a coder at St. Alphonsus Regional Medical Center in Boise, Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer and AHIMA ACE mentor. Email her at LORIWEBB@sarmc.org or webbservices.lori@gmail.com.



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