Teaching Physician Guidelines: Not Just for the Academic Practice

October 04, 2010

Most physicians working for the faculty practice plans associated with an academic medical center are familiar with the physician at teaching hospital (PATH) documentation requirements for any service where there is medical student or resident participation. However, some physicians in private practices may also be affiliated with a teaching hospital where there is medical student or resident participation in the services the physicians provide to their patients. Though not part of a faculty practice plan, the PATH participation and documentation requirements still apply when billing for the service.

Chapter 12, section 100 of the Medicare claims processing manual discusses the circumstances under which an attending physician may bill for a service where there is medical student or resident participation. The following are excerpts from the manual:

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 Medicare physician fee schedule.

Services furnished in teaching settings are paid under the Medicare physician fee schedule if they are:

  • Personally furnished by a physician who is not a resident.
  • Furnished by a resident when a teaching physician is physically present during the critical or key portions of the service.
  • Furnished by residents under a primary care exception within an approved graduate medical education program.

Both residents and teaching physicians may document physician services in the patient’s medical record. The documentation must be dated and contain a legible signature or identity and may be:

  • Dictated and transcribed.
  • Typed.
  • Hand-written.
  • Computer-generated.

A macro is a command in a computer or dictation application in an electronic medical record that automatically generates predetermined text that is not edited by the user. The teaching physician may use a macro as the required personal documentation if he or she personally adds it in a secured or password-protected system. In addition to the teaching physician’s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical-necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. If both the resident and the teaching physician use macros only, this is considered insufficient documentation.

Evaluation and Management (E/M) Services: when teaching physicians bill E/M services, they must personally document at least the following:

  • That they performed the service or were physically present during the critical or key portions of the service furnished by the resident.
  • His or her participation in the management of the patient.

The teaching physician must document that he/she personally saw the patient, personally performed critical or key portions of the service and participated in the management of the patient. The teaching physician’s note should reference the resident’s note. For payment, the composite of the teaching physician’s entry and the resident’s entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician.
On medical review, the combined entries into the medical record by the teaching physician and resident constitute the documentation for the service and together must support the medical necessity of the service. Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician.

E/M Documentation Provided by Students: any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements (other than the review of systems [ROS] and/or past, family and/or social history [PFSH], which are taken as part of an E/M service and are not separately billable). Students may document services in the medical record; however, the teaching physician may only refer to the student’s documentation of an E/M service that is related to the ROS and/or PFSH. The teaching physician may not refer to a student’s documentation of physical examination findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and re-document the history of present illness and perform and re-document the physical examination and medical decision-making activities of the service.

Example of acceptable documentation:

  • “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”

Examples of unacceptable documentation:

  • “Agree with above,” followed by legible countersignature or identity.
  • “Rounded, reviewed, agree,” followed by legible countersignature or identity.
  • “Discussed with resident. Agree,” followed by legible countersignature or identity.
  • “Seen and agree,” followed by legible countersignature or identity.
  • “Patient seen and evaluated,” followed by legible countersignature or identity.
  • A legible countersignature or identity alone.

Such documentation is not acceptable because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient and/or had any involvement with the plan of care.

Surgery (Including Endoscopic Operations): the teaching surgeon is responsible for the preoperative, operative and postoperative care of the beneficiary.
To bill Medicare for endoscopic procedures, the teaching physician must be present during the entire viewing. The entire viewing starts at the time of insertion of the endoscope and ends at the time of removal of the endoscope. Viewing of the entire procedure through a monitor in another room does not meet the teaching physician presence requirement.

For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made.

To summarize the key points:

  • To bill for a service that involves students or residents, the teaching physician must meet the participation and documentation requirements under PATH.
  • A signature of the attending or “seen and agree” are not sufficient to document the service.
  • The documentation must clearly identify what part of the service was performed by the student, resident and attending.
  • Unless there is documentation by the attending of his/her participation as defined by the regulations, the service is not billable by the attending.

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