(Medicare Claims Processing Manual)

To bill Medicare for endoscopic procedures (excluding endoscopic surgery that follows the surgery policy in subsection A, above), 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.  6. Interpretation of Diagnostic Radiology and Other Diagnostic Tests   Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician.  If the teaching physicians signature is the only signature on the interpretation, Medicar e assumes that he/she is indicating that he/she personally performed the interpretation.  If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the residents interpretation and either agrees with it or edits the findings.  Medicare does not pay for an interpretation if the teaching physician only countersigns the residents interpretation.  100.1.3 - Psychiatry  (Rev. 811, Issued: 01-13-06, Effective: 01-01-06, Implementation: 02-13-06)  The general teaching physician policy set forth in 100.1 applies to psychiatric services.  For certain  psychiatric services, the requirement for the presence of the teaching physician during the service may be met by concurrent observation of the service by use of a one-way mirror or video equipment.  Audio-only equipment does not satisfy to the physical pr esence requirement.  In the case of time -based services such as individual medical psychotherapy, see 100.1.4, below.  Further, the teaching physician supervising the resident must be a physician, i.e., the Medicare teaching physician policy does not apply to psychologists who supervise psychiatry residents in approved GME programs. 100.1.4 - Time -Based Codes  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  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.  For example, a code that specifically describes a service of from 20 to 30 minutes may be paid only if the teaching physician is physically present for 20 to 30 minutes.  Do not add time spent by the resident in the absence of the teaching physician to time spent by the resident and teaching physician with the beneficiary or time spent by the teaching physician alone with the beneficiary.  Examples of codes fa lling into this category include:    Individual medical psychotherapy (HCPCS codes 90804 -  90829);    Critical care services (CPT codes 99291 -99292);    Hospital discharge day management (CPT codes 99238- 99239);   E/M codes in which counseling and/or coordination of care dominates (more than 50 percent) of the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service;    Office/outpatient E/M visit codes for which total time is used for the visit level selection.  For purposes of selecting visit level, only count time spent by the teaching physician performing qualifying activities listed by CPT (with or without direct pat ient contact on the date of the encounter), including the time the teaching physician is present when the resident is performing such activities;    Prolonged services (CPT codes 99358- 99359); and   Care plan oversight (HCPCS codes G0181 -  G0182).  100.1.5 - Other Complex or High -Risk Procedures  (Rev. 1, 10- 01-03)  In the case of complex or high- risk procedures for which national Medicare policy,  local policy, or the CPT description indicate that the procedure requires personal (in person) supervision of its performance by a physician, pay for the physician services  associated with the procedure only when the teaching physician is present with the resident.  The presence of the resident alone would not establish a basis for fee schedule payment for such services.  These procedures include interventional radiologic and cardiologic supervision and interpretation codes, cardiac catheterization, cardiovascular stress tests, and trans -esophageal echocardiography.   100.1.6 - Miscellaneous  (Rev. 1458, Issued: 02- 22-08, Effective: 03 -24-08, Implementation: 03- 24-08)  In the case of maternity services furnished to women who are eligible for Medicare, apply the physician presence requirement for both types of delivery as A/B MACs (B) would for surgery.  In order to bill for the procedure, the teaching physician must be present for the delivery.  These procedure codes are somewhat different from other surgery codes in that there are separate codes for global obstetrical care (prepartum, delivery, and postpartum) and for deliveries only.  In situations in which the teaching physicians only involvement was at the time of delivery, the teaching physician should bill the delivery only code.  In order to bill for the global procedures, the teaching physician must be present for the minimum indicated number of visits when such a  number is specified in the description of the code.  This policy differs from the policy on general surgical procedures under which the teaching physician is not required to be present for a specified number of visits.  In the case of end stage renal related visits furnished under the monthly capitation payment method (MCP), the physician presence policy as discussed in 100.1 applies.  Patient visits furnished by residents may be counted toward the MCP visits if the teac hing MCP physician is physically present during the visit. The teaching physician may utilize the residents notes, however the teaching physician must document his or her physical presence during the visit(s) furnished by the resident and that he or she r eviewed the residents notes.  The teaching physician could document these criteria as part of an extensive once a month MCP note.   100.1.7 - Assistants at Surgery in Teaching Hospitals  (Rev. 811, Issued: 01- 13-06, Effective: 01 -01-06, Implementation: 02- 13-06)  A. General   A/B MACs (B) do not pay for the services of assistants at surgery furnished in a teaching hospital which has a training program related to the medical specialty required for the surgical procedure and has a qualified resident available to perform the servi ce unless the requirements of one of subsections C, D, or E are met. Each teaching hospital has a different situation concerning numbers of residents, qualifications of residents, duties of residents, and types of surgeries performed.   Contact those affected by these instructions to learn the circumstances in individual teaching hospitals.  There may be some teaching hospitals in which A/B MACs (B) can apply a presumption about the availability of a qualified resident in a training progr am related to the medical specialty required for the surgical procedures, but there are other teaching hospitals in which there are often no qualified residents available.  This may be due to their involvement in other activities, complexity of the surgery, numbers of residents in the program, or other valid reasons. A/B MACs (B) process assistant at surgery claims for services furnished in teaching hospitals on the basis of the following certification by the assistant, or through the use of modifier - 82 which indicates that a qualified resident surgeon was not available.  This certification is for use only when the basis for payment is the unavailability of qualified residents.   I understand that 1842(b)(7)(D)  of the Act (follow the link and select the applicable title) generally prohibits Medicare physician fee schedule payment for the services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such services. I cer tify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the services. I further understand that these services are subject to post- payment review by the A/B MAC (B).  A/B MACs (B) retain the claim and certification for four years and conduct post-payment reviews as necessary.  For example, A/B MACs (B) investigate situations in which it is always certified that there are no qualified residents available, and undertake recovery if warranted.   Assistant at surgery claims denied based on these instructions do not qualify for payment under the limitation on liability provision.  B. Definition   An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure.  (Note that a nurse practitioner, physician assistant or clinical nurse specialist who is authorized to provide such services under State law can also serve as an assistant at surgery).  The conditions for coverage of such services in teaching hospitals are more restrictive than those in other settings because of the availability of residents who are qualified to perform this type of service.  C. Exceptional Circumstances   Payment may be made for the services of assistants at surgery in teaching hospitals, subject to the special limitation in 20.4.3 notwithstanding the availability of a qualified resident to furnish the services.  There may be exceptional medical circumstances (e.g., emergency, life- threatening situations such as multiple traumatic injuries) which require immediate treatment.  There may be other situations in which the medical staff may find that exceptional medical circumstances justify the services of a ph ysician assistant at surgery even though a qualified resident is available.  D. Physicians Who Do Not Involve Residents in Patient Care  Payment may be made for the services of assistants at surgery in teaching hospitals, subject to the limitations in 20.4.3, above, if the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or postope rative care of his or her patients.  Generally, this exception is applied to community physicians who have no involvement in the hospitals GME program.  In such situations, payment may be made for reasonable and necessary services on the same basis as wou ld be the case in a nonteaching hospital.  However, if the assistant is not a physician primarily engaged in the field of surgery, no payment be made unless either of the criteria of subsection E is met.   E. Multiple Physician Specialties Involved in Surgery   Complex medical procedures, including multistage transplant surgery and coronary bypass, may require a team of physicians. In these situations, each of the physicians performs a unique, discrete function requiring special skills integral to the total proce dure.  Each physician is engaged in a level of activity different from assisting the surgeon in charge of the case.  The special payment limitation in 20.4.3 is not applied.  If payment is made on the basis of a single team fee, additional claims are deni ed.  The A/B MAC (B) will determine which procedures performed in the service area require a team approach to surgery.  Team surgery is paid for on a By Report basis.  The services of physicians of different specialties may be necessary during surgery when each specialist is required to play an active role in the patients treatment because of the existence of more than one medical condition requiring diverse, specialize d medical services.  For example, a patients cardiac condition may require a cardiologist be present to monitor the patients condition during abdominal surgery.  In this type of situation, the physician furnishing the concurrent care is functioning at a different level than that of an assistant at surgery, and payment is made on a regular fee schedule basis.  100.1.8 - Physician Billing in the Teaching Setting  (Rev. 2303, Issued: 09- 14-11, Effective: 06 -01-11, Implementation: 07- 26-11)  A. A/B MAC (B) Claims   The method by which services performed in a teaching setting must be billed is determined by the manner in which reimbursement is made for such services.  For A/B MACs (B), the shared system suspends claims submitted by a teaching physician, for review.   B. Billing Modifiers   Effective January 1, 1997, services furnished by teaching physicians involving a resident in the care of their patients must be identified as such on the claim.  To be payable, claims for services furnished by teaching physicians involving a resident must comply with the requirements in sections 100.1 through 100.1.6 of this chapter, as applicable.  Claims for services meeting these requirements must show either the GC or GE modifier as appropriate and described below.   1. Teaching Physician Services that Meet the Requirement for Presence During the Key/Critical Portion of the Service   Claims for teaching physician services in compliance with the requirements outlined in sections 100.1 - 100.1.6 of this chapter must include a GC modifier for each service, unless the service is furnished under the primary care center exception described in section 100.1.1C (refer to number 2, below).  When a physician (or other appropriate billing provider) places the GC modifier on the claim, he/she is certifying that the teaching physician has complied with the requirements in sections 100.1 through 100.1.6.  2. Teaching Physician Services Under the Exception for E/M Services Furnished in Primary Care Centers   Teaching physicians who meet the requirements in section 100.1.1C of this chapter must provide their A/B MAC (B) with an attestation that they meet the requirements. Claims for services furnished by teaching physicians under the primary care center excepti on must include the GE modifier on the claim for each service furnished under the primary care center exception.   100.2 - Interns and Residents  (Rev. 1, 10- 01-03) B3-2020.8, B3- 8030