Practice Economics

Academic Institutions


 

Hospitalists work in many types of facilities, including academic centers that utilize residents (including interns) in healthcare delivery. Medical and surgical services furnished by a resident within the scope of the training program are covered as provider services and paid by Medicare through direct Graduate Medical Education (GME) and Indirect Medical Education (IME) payments; the services of the resident may not be billed or paid for using the Medicare Physician Fee Schedule.

Similarly, the teaching physician is not paid for the resident’s work. The teaching physician is paid for their participation in patient care. In other words, payment is provided to the teaching physician for services that are:

  • Furnished by a physician who is not a resident; or
  • Furnished by a resident with a teaching physician physically present during the critical or key portion(s) of the service.

Teaching physicians participate in evaluation and management (E/M) services with residents in several ways. Consider the following teaching physician scenarios:

Using Medicare-approved linkage statements will ensure compliance with teaching physician rules.

Scenario 1: “Stand-Alone” Service

The resident sees a patient in the morning. The teaching physician independently sees the patient later that same day, performing all required elements to support their own bill (e.g. 99233: subsequent hospital care, per day, which requires at least two of these three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making). When documenting, the teaching physician can write their own note with or without any of the residents’ information. The attending note “stands alone” in support of the reported visit level. Alternatively, the teaching physician might “link to” the resident note, instead of personally redocumenting the entire service.

Appropriate documentation includes teaching physician notation of the provided critical or key portion(s) of the service and the involvement in patient management. The visit level is based upon the combined documentation, both teaching physician and resident.

Definitions for teaching-physician services

  • Resident: An individual who participates in an approved GME program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary (FI). A staff or faculty appointment, or participating in a fellowship, does not by itself alter the status of “resident.” Additionally, this status remains unaffected regardless of whether a hospital includes the physician in its full-time equivalency count of residents.
  • Student: An individual who participates in an accredited educational program that is not an approved GME program. A student is never considered to be an intern or a resident. Medicare does not pay for any service furnished by a student.
  • Teaching physician: A physician (other than a resident) who involves residents in the care of his or her patients.
  • Direct medical and surgical services: Services to individual beneficiaries that are either personally furnished by a physician or furnished by a resident under the supervision of a physician in a teaching hospital. All payments for such services are made by the FI for the hospital.
  • Teaching setting: Any provider, hospital-based provider, or nonprovider setting in which Medicare payment for the services of residents is made by the FI under the direct GME payment methodology, or freestanding skilled nursing facility or home health agency in which such payments are made on a reasonable cost basis.
  • Critical or key portion: The part(s) of a service that the teaching physician determines critical or key. In most cases, the terms are interchangeable. —CP

Using Medicare-approved linkage statements will ensure compliance with teaching physician rules. Examples:

  • “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 saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
  • “I saw and examined the patient. I agree with the resident’s note, except the heart murmur is louder, so I will obtain an echo to evaluate.”

Each of the above linkage statements is acceptable, and “more is always better.” The last example best identifies the teaching physician’s involvement in patient management and best supports other regulatory goals and quality initiatives of the current healthcare environment.

Scenario 2: “Supervised” Service

The resident and the teaching physician see the patient at the same time. The teaching physician supervises the resident’s performance of the required service elements or personally performs elements separate from those completed by the resident. Despite personal supervision, the attending still must document their presence during the encounter, performance of the critical or key portion(s) of the service, and involvement in patient management. The visit level is based upon the combined documentation.

Medicare-accepted teaching physician statements associated with this scenario include:

  • “I was present with the 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 the patient with the resident and agree with the resident’s findings and plan.”

These generalized statements will be accepted for billing under teaching physician rules. However, documenting patient-specific elements of the assessment and plan unequivocally demonstrates teaching- physician involvement in patient care and the quality of care provided.

Scenario 3: The “Shared” Service

The resident performs a portion or all of the required service elements without teaching-physician presence and documents this service. The teaching physician then independently performs only the critical or key portion(s) of the service and, as appropriate, discusses the case with the resident. As in the other scenarios, the attending documents the presence and performance of the critical or key portion(s) of the service, as well as involvement in patient management. The teaching physician selects the visit level based upon the combined documentation of the teaching physician and resident.

Such Medicare-approved statements for use by teaching physicians under this scenario include:

  • “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.”
  • “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
  • “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
  • “I saw and evaluated the patient. Agree with resident’s note, but lower extremities are weaker, now 3/5; MRI of L/S spine today.”

Regardless of the timing between the attending and the resident encounter represented in each scenario, the teaching physician cannot “link to” a resident note that has not been written. More specifically, if the resident’s note has not been documented at the time the teaching physician writes their note, the teaching physician can’t link to the resident’s note or consider it for billing purposes.

Time-Based Exception

Time-based E/M services (e.g. critical-care services, discharge-day management, prolonged care, etc.) do not follow the same guideline as the standard E/M services, which are selected upon the level of history, exam, and decision-making. Only the billing provider’s time counts toward the reported visit level. This means that the teaching physician must be present for the entire period of time for which the claim is made. Documentation should identify the teaching physician’s total visit time (spent on the unit/floor for inpatient services), including face-to-face time with the patient. Time spent by the resident without the presence of the teaching physician does not count toward the teaching physician’s reported time. Additionally, time spent “teaching” the resident cannot be attributed to the teaching physician’s visit time.

Student Notes

Per Medicare guidelines, students (medical, nurse practitioner, etc.) can document services in the medical record. However, the teaching physician can only refer to medical student documentation associated with the review of systems and/or past/family/social history. The teaching physician cannot refer to a student’s documentation of physical exam findings or medical decision-making.

If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness, as well as perform and redocument the physical exam and medical decision-making activities of the service. The teaching physician then selects the visit level and documents service. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

  1. Guidelines for Teaching Physicians, Interns, Residents. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed May 6, 2011.
  2. Medicare Claims Processing Manual: Chapter 12, Section 100. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed May 6, 2011.
  3. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed May 6, 2011.
  4. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2008. Northbrook, IL: American College of Chest Physicians, 2008; 279-285.
  5. Pohlig, C. Evaluation & Management Services: An Overview. In: Coding for Chest Medicine 2011. Northbrook, IL: American College of Chest Physicians, 2010; 323-330.
  6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011.

READER Q&A

CMS Suggests Extended Observation Should Be Infrequent Occurrence

Question: I read the March 2011 “Billing and Coding” article regarding the new CPT codes and have the following inquiry: Often, as a hospitalist, I will get a lot of pushback from our UM reviewers and case managers when observation patients stay longer than 48 hours. This is due to the Centers for Medicare & Medicaid Services’ 48-hour observation policy. It sounds like the CPT is trying to address this issue by creating these new codes and have patients stay longer as observation. This seems in conflict with the goal of CMS to have patients stay only for 48 hours as observation and then be converted to inpatient if they fail 48 hours of observation.

Answer: While the goal of CMS is to maintain a limit of hospital observation services, there seems to be a growing trend of extended observation care (>48 hours) over the past several years. CMS recognizes that there might be extenuating circumstances, which might require an observation stay of more than 48 hours, but suggests that this should be an infrequent occurrence. Typically, the physician is able to determine if the patient should be admitted to the hospital or discharged to home within 48 hours.

Other factors affect observation care services. Only the attending of record can bill for initial hospital care (99218-99220).1 Prior to Jan. 1, 2010, consultants could provide their services, as appropriate, and report consultation services. With the elimination of payment for consultation services in 2010, the consultant was only allowed to report outpatient/office codes (99201-99215) for the hospital observation care.

Additionally, with private payors able to “downgrade” inpatient care to observation both during and after discharge (unlike Medicare), inpatient stays greater than 48 hours were being reversed and reported with office codes (99212-99215) on the days between the initial admission service (99218-99220) and the discharge service (99217).1 The office codes would then be met with denials for “missing referrals,” and subsequent attempts to appeal would often provide no reimbursement.

These combined factors led to the creation of a more viable solution for interim observation days: subsequent observation care (99224-99226).2 The attending of record reports these codes on stays that spanned three calendar days but still less than 48 hours; the consultant reports these for their rendered services; and the private payors can make these codes exempt from requiring referrals when downgrading inpatient stays.

References

  1. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:12-13.
  2. Medicare Benefit Policy Manual: Chapter 6, Section 20.6A. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/Downloads/bp102c06.pdf. Accessed April 20, 2011.

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