WITH A BRAND NEW CLASS of residents arriving in teaching hospitals in just a few months, it’s a good time to take another look at teaching physician rules. I’ll start with this quick reminder of a change last year: Supervising physicians are no longer required to re-document medical students documentation of a service.
That, of course, comes with the caveat that teaching physicians must still personally perform (or re-perform) the physical exam and medical decision-making involved with whatever evaluation and management service is being billed. While the modification may seem small, it should be saving supervising doctors some time.
While the rest of this column won’t highlight recent changes, that doesn’t mean you should stop reading. Although teaching rules (and how they affect documentation and billing) have remained the same, not following those rules still gets hospitals—and doctors—in trouble. You still need to pay attention to the rules and understand their nuances.
Time-based codes and admissions
Let’s start with time-based codes for critical care services, prolonged services and hospital discharge-day management, just to name a few. For time-based codes, teaching physicians must be present for the entire period of time for which a claim is being made.
The CMS applies a lot of scrutiny to the documentation of teaching physicians.
For instance, if a resident performs discharge services, reports CPT code 99239 (discharge, 30 minutes or more) and spends 50 minutes doing the service, a teaching physician must be present the entire 50 minutes. Any time spent by the resident without the teaching physician present cannot be reported.
As for admissions, say residents admit a patient at night while a supervising physician doesn’t see the patient until the next day. Supervising physicians must document that they saw the patient and participated in that patients’ management. However, they may reference a resident’s note instead of re-documenting any of the history, exam or decision-making, as long as the patient’s condition hasn’t changed and the teaching physician agrees with the residents note.
But supervising physicians have to document any change in a patient’s condition that requires the note to be amended. Further, the bill must reflect the date that supervising physicians saw the patient and specify their personal work in patient management.
Then there’s the issue of minor procedures. Teaching rules indicate that residents (but not medical students) can perform procedures that typically take five minutes or less to complete and do not require significant medical decision-making.
By “minor procedures,” I don’t mean those being performed on procedure services where hospitalist attendings supervise residents while training them to do bedside procedures such as paracentesis and thoracentesis, for instance, or placing central lines.
What I’m referring to is when residents on rotation in the emergency department—and hospitalists are in the emergency department all the time—are instructed to place some sutures in a patient. For hospitalists to be able to bill that service as teaching physicians, they must be present for that entire procedure.
The same is true when residents perform an endoscopic procedure; while that could relate to a residents specialty rotation in GI, it could also be part of a resident’s primary care rotation. Teaching physicians must be present at the bedside during the entire viewing time.
According to the teaching rules, viewing time starts at the time the endoscope is inserted and ends when the endoscope is removed. And by “must be present,” I mean: Viewing the procedure via a monitor in another room does not meet the requirement of a teaching physician being personally present.
Then there’s the issue of residents (again, not medical students) interpreting diagnostic radiology services and other diagnostic tests. While that may be especially true during residents’ radiology rotation, many internal medicine services may still send residents down to radiology to read X-rays.
A teaching physician must perform or review residents’ interpretation. The Centers for Medicare and Medicaid Services (CMS) assumes that if a teaching physicians signature is the only one on the interpretation, that doctor personally performed the service him- or herself. If a resident prepares and signs the interpretation, the teaching physician must still document that he/she personally reviewed not only the image but the interpretation as well and agrees with it. When teaching physicians don’t agree with a residents’ interpretation, they must edit the findings.
If you work in a teaching setting with residents and medical students, it is well worth your time to review the teaching physician rules, perhaps on an annual basis. You can find them on the CMS Web site (CMS.gov) in the Internet-Only Manual 100-4 (Claims Processing Manual), chapter 12, section 100. They don’t read like a Stephen King novel—but then, reading Stephen King won’t keep you off Medicare’s radar. The CMS applies a lot of scrutiny to teaching physician documentation, so take the time to know what’s expected.
Sue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience.Published in the April 2019 issue of Today’s Hospitalist
Thanks for the enlighting article. I’m not sure if understood this right so please clarify further: “For instance, if a resident performs discharge services, reports CPT code 99239 (discharge, 30 minutes or more) and spends 50 minutes doing the service, a teaching physician must be present the entire 50 minutes. Any time spent by the resident without the teaching physician present cannot be reported.” Do you mean the attending physician should be physically present with the resident in the room doing the discharge, or he can be in his office reviewing the discharge orders, or what exactly is meant by… Read more »
Thank you for your question. Sue Lewis responds: The CMS teaching physician rules offer clear direction when it comes to the requirements for a teaching physician to be able to bill for services provided by a resident. The Medicare Internet-Only Claims Processing Manual, 100-4, Chapter 12, Section 100 defines physically present as follows: Physically Present The teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service. In addition, Section 100.1.4 addresses time-based codes, which includes hospital discharges. It states: Time-based… Read more »