Untangling Medicare's Teaching Physician Billing Rules ...

Untangling Medicare's Teaching Physician Billing Rules

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How do you get approved for the primary care exception?

Can the preceptor write the note and sign off only when both a resident and the preceptor see's the patient?

Per Medicare, "For this exception to apply, a center must attest in writing that all the following conditions are met for a particular residency program. Prior approval is not necessary, but centers exercising the primary care exception must maintain records demonstrating that they qualify for the exception."

That is the best policy, since Medicare expects the TP to attest in his/her note that the documentation of the resident has been reviewed. However, some statements have come from Medicare that indicated that as long as the TP had at least DISCUSSED the resident's service with the resident, the TP can go ahead and write their TP note assuming that the resident will simply document their service as they described it to the TP. Other statements indicate that the TP should not document until the resident has completed his/her note. That is the best policy in my opinion.

Do we have to put the GC modifier on higher level such as Yes. Per Medicare, only Levels 1-3 may be billed using the

99214 office coding? I realize that level 99213 or lower PCE location allowance. They say that "If a service other

has to have GE or GC modifiers.

than those listed above needs to be furnished [an E/M

higher than level 3, or any other service], then the general

teaching physician policy set forth in ?100.1 applies."

Do you know if other payers will deny claims usimg mod I don't know of any that will deny claims based solely on

GE/GC

the fact that the GC or GE modifiers were used.

Are there any exceptions when a dental resident (DDS) The TP requirements would apply. comes to the ED and is supervised by the ED physician or do the same TP requirements apply?

Tricare will deny for modifier GE only..they want the GC If any specific payer directs you to use only the GC

only

modifier, or neither TP modifier, then you would of course

follow their instructions.

Is there a differnce between a resident and student?

There is a WORLD of difference. The TP billing rules apply almost exclusively to residents. Per Medicare, "A student is never considered to be an intern or a resident. Medicare does not pay for any service furnished by a student." TPs may refer to ROS and PFSH written by students--that's it.

Can an attending refer to the resident team to refer back to all notes from the residents for the day?

I can't say for sure. That would be a judgment call by an auditor. Preferably, the TP would comment that he/she agrees with the assessment/plan of resident X as expressed in his note at X PM, or similar.

What if the resident sees the patient late at night for a "consultation"? If the Teaching MD goes into see the patient the next DOS (within 24 hrs), can both sets of documentation be combined for code level? Since Medicare does not recognize the consult codes, initial hospital evaluation codes (99221-99223) would be reported.

The only scenario in which Medicare specifically allows a TP to link to a resident note from a prior DOS is the latenight resident admission scenario. I wouldn't assume this allowance extends to any other situation until such time as Medicare states this. As such, I would recommend that the TP bill a service for the current DOS based on his/her service and documentation.

So on the above question...if the resident is ortho and the The TP would bill for his/her individual service as

TP is ortho, are you saying if it was a consult we should not documented. The safe practice would be to only allow the

bill?

TP to refer to a resident's note from earlier in the SAME

DOS unless the scenario is one involving a late-night

resident admission.

Thank you. Regarding the question on resident seeing patient late at night for consultation and TP goes in next day......I wonder whether the initial hospital evaluation codes would be acceptable to report in this scenario since consultation codes are not recognized? Is this a stretch?

Per Medicare, the TP would bill using the Initial Care codes for late-night resident admission situations using the DOS of their TP note, not the prior DOS of the resident admission.

Could you comment on this scenario? resident sees a patient without a teaching physician, therefore the visit is not billed. However, the resident advised & scheduled the patient for a screening colonoscopy. On the day of the procedure, the teaching physician is present for the entire procedure. Is the procedure still billable? Or is it invalid because teh teaching physician did not supervise the visit when the procedure was decided?

I wouldn't think Medicare would deny the subsequent services at which the TP met the participation requirements as long as the service decided upon by the resident was deemed medically necessary by the TP. If, on the other hand, the resident decided during the unsupervised service that the patient needed to have a procedure that was later deemed by the TP to be unwarranted, then the residentordered service would not be billed.

The American Academy of Pediatrics says that for neonatal Medicare's TP rules don't mention that requirement, or

CC, a "problem focused exam" for attendings is required. interpret how outside entities' recommendations should be

Do you feel a provider documenting " a problem focused documented. Medicare's TP rules require the TP to

physical exam was performed" is acceptable?

specifically document his/her contribution to the patient's

care, but don't mandate that this work reach any certain

level of history-taking or exam. If the provider's work

consisted of a certain level of exam, the specific

components of his/her work should be documented to

demonstrate to Medicare exactly what the TP did.

Can a Nurse Practioner or a Physician Assistant be a teaching physician? In a family practice clinic claiming the primary care exception... would it be acceptable for the TP to be in another building but on campus? Would this constitute "immediate availability"?

No, a non-physician practitioner can never be considered to be a TP. Probably not. Medicare says the TP must "Review the care provided by the resident during or immediately after each visit." Medicare may have a hard time believing that the TP was running back and forth between buildings so that they could IMMEDIATELY meet each resident coming out of the exam room for each encounter to review the service with them.

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