(Medicare Claims Processing Manual)

100.1.1 - Evaluation and Management (E/M) Services  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  A. General Documentation Requirements   Evaluation and Management (E/M) Services --  For a given encounter, the selection of the appropriate level of E/M service should be determined according to the code definitions in the American Medical Associations Current Procedural Terminology (CPT) book and any applicable documentation guidelines.  For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:    That the teaching physician performed the service or was physically present during the key  or critical portions of the service when performed by the resident;  and   The participation of the teaching physician in the management of the  patient.   The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.   B. E/M Service Documentation Provided By  Students   Any contribution and participation of students to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.   Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must pers onally perform (or re -perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re -documenting this work.  C. Exception for E/M Services Furnished in Certain Primary Care Centers   Teaching physicians providing E/M services with a GME program granted a primary care exception may bill Medicare for lower and mid -level E/M services provided by residents. Effective January 1, 2022, teaching physicians may use only medical decision making (MDM) for purposes of E/M visit level selection when billing the Medicare program under the physician fee schedule for office/outpatient E/M visits under this primary care exception. For the E/M codes listed below, teaching physicians may submit claims fo r services furnished by residents in the absence of a teaching physician:    New Patient  Established Patient  99201  99211  99202  99212  99203  99213   Effective January 1, 2005, the following code is included under the primary care exception: HCPCS code G0402 (Initial preventive physical examination; face -to-face visit services limited to new beneficiary during the first 12 months of Medicare enrollment).   Effective January 1, 2011, the following codes are included under the primary care exception: HCPCS codes G0438 (Annual wellness visit, including personal preventive plan service, first visit) and G0439 (Annual wellness visit, including personal preventive  plan service, subsequent visit).  If a service other than those listed above needs to be furnished, then the general teaching physician policy set forth in 100.1 applies. For this exception to apply, a center must attest in writing that all the following conditions are met for a particula r residency program. Prior approval is not necessary, but centers exercising the primary care exception must maintain records demonstrating that they qualify for the exception.   The services must be furnished in a center located in the outpatient department of a hospital or another ambulatory care entity in which the time spent by residents in patient care activities is included in determining direct GME payments to a teaching hospital by the hospitals A/B MAC (A). This requirement is not met when the resident is assigned to a physicians office away from the center or makes home visits. In the  case of a nonhospital entity, verify with the A/B MAC (A) that the entity meets the requirements of a written agreement between the hospital and the entity set forth at 42 CFR 413.78(e)(3)(ii).   Under this exception, residents providing the billable patient care service without the physical presence of a teaching physician must have completed at least 6 months of a GME approved residency program. Centers must maintain information under the provisi ons at 42 CFR 413.79(a)(6).   Teaching physicians submitting claims under this exception may not supervise more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability. Teaching physicians may include residents with les s than 6 months in a GME approved residency program in the mix of four residents under the teaching physicians supervision.  However, the teaching physician must be physically present for the critical or key portions of services furnished by the residents  with less than 6 months in a GME approved residency program. That is, the primary care exception does not apply in the case of residents with less than 6 months in a GME approved residency program.   Teaching physicians submitting claims under this exception must:    Not have other responsibilities (including the supervision of other personnel) at the time the service was provided by the  residents;    Have the primary medical responsibility for patients cared for by the  residents;    Ensure that the care provided was reasonable and  necessary;    Review the care provided by the residents during or immediately after each visit. This must include a review of the patients medical history, the residents findings on physical examination, the patients diagnosis, and treatment plan (i.e., record of tests and therapies);  and  Patients under this exception should consider the center to be their primary location for health care services. The residents must be expected to generally provide care to the same group of established patients during their residency training. The types of  services furnished by residents under this exception include:    Acute care for undifferentiated problems or chronic care for ongoing  conditions including chronic mental  illness;   Coordination of care furnished by other physicians and providers;  and,   Comprehensive care not limited by organ system or  diagnosis.  Residency programs most likely qualifying for this exception include family practice, general internal medicine, geriatric medicine, pediatrics, and obstetrics/gynecology.   Certain GME programs in psychiatry may qualify in special situations such as when the program furnishes comprehensive care for chronically mentally ill patients. These would be centers in which the range of services the residents are trained to furnish, and actually do furnish, include comprehensive medical care as well as psychiatric care. For example, antibiotics are being prescribed as well as psychotropic drugs.   The patient medical record must document the extent of the teaching physicians participation in the review and direction of the services furnished to each beneficiary.  The extent of the teaching physicians participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.   100.1.2 - Surgical Procedures  (Rev. 2303, Issued: 09- 14-11, Effective: 06 -01-11, Implementation: 07- 26-11)  In order to  bill for surgical, high- risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.   A. Surgery (Including Endoscopic Operations)   The teaching surgeon is responsible for the preoperative, operative, and postoperative care of the beneficiary.  The teaching physicians presence is not required during the opening and closing of the surgical field unless these activities are considered t o be critical or key portions of the procedure.  The teaching surgeon determines which postoperative visits are considered key or critical and require his or her presence.  If the postoperative period extends beyond the patients discharge and the teaching surgeon is not providing the patients follow -up care, then instructions on billing for less than the global package in 40 apply.  During non- critical or non -key portions of the surgery, if the teaching surgeon is not physically present, he/she must be i mmediately available to return to the procedure, i.e., he/she cannot be performing another procedure.  If circumstances prevent a teaching physician from being immediately available, then he/she must arrange for another qualified surgeon to be immediately available to assist with the procedure, if needed.   1. Single Surgery   When the teaching surgeon is present for the entire surgery, his or her presence may be demonstrated by notes in the medical records made by the physician, resident, or operating room nurse.  For purposes of this teaching physician policy, there is no required information that the teaching surgeon must enter into the medical records.   2. Two Overlapping Surgeries   In order to bill Medicare for two overlapping surgeries, the teaching surgeon must be present during the critical or key portions of both operations.  Therefore, the critical or key portions may not take place at the same time.  When all of the key portions of the initial procedure have been completed, the teaching surgeon may begin to become involved in a second procedure.  The teaching surgeon must personally document in the medical record that he/she was physically present during the critical or key port ion(s) of both procedures.  When a teaching physician is not present during non- critical or non -key portions of the procedure and is participating in another surgical procedure, he/she must arrange for another qualified surgeon to immediately assist the resident in the other case should the need arise.  In the case of three concurrent surgical procedures, the role of the teaching surgeon (but not anesthesiologist) in each of the cases is classified as a supervisory service to the hospital rather than a physician service to an individual patient and is not payable under the physician fee schedule.  3. Minor Procedures   For procedures that take only a few minutes (five minutes or less) to complete, e.g., simple suture, and involve relatively little decision making once the need for the operation is determined, the teaching surgeon must be present for the entire procedure in order to bill for the procedure.  4. Anesthesia   Medicare pays at the regular fee schedule level if a teaching anesthesiologist is involved in a single procedure with one resident.  The teaching physician must document in the medical records that he/she was present during all critical (or key) portions of the procedure.  The teaching physicians physical presence during only the preoperative or postoperative visits with the beneficiary is not sufficient to receive Medicare payment. If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a nonphysician anesthetist and the service is furnished prior to January 1, 2010, Medicare pays for the anesthesiologists services as medical direction.  In those cases where the teaching anesthesiologist is involved in two concurrent anesthesia cases with residents on or after January 1, 2004, the teaching anesthesiologist may bill the usual base units and anesthesia time for the amount of time he/she is p resent with the resident.  The teaching anesthesiologist can bill base units if he/she is present with the resident throughout pre and post anesthesia care.  The teaching anesthesiologist should use the AA modifier to report such cases.  The teaching ane sthesiologist must document his/her involvement in cases with residents.  The documentation must be sufficient to support the payment of the fee and available for review upon request.  For anesthesia services furnished on or after January 1, 2010, payment may be made under the Medicare physician fee schedule at the regular fee schedule level if the teaching anesthesiologist is involved in the training of a resident in a single anesthesia case, two concurrent anesthesia cases involving residents, or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules.  To qualify for payment, the teaching anesthesiologist, or different anesthesiologists in the same anesthesia group, must be present during all critical or key portions of the anesthesia service or procedure involved.  The teaching anesthesiologist (or another anesthesiologist with whom the teaching physician has entered into an arrangement) must be immediately available to furnish anesthesia services during the entire procedure.  The documentation in the patients medical records must indicate the teaching physicians presence during all critical or key portions of the anesthesia procedure and the immediate availability of another teaching anesthesiologist as necessary.  If different teaching anesthesiologists are present with the resident during the key or critical periods of the resident case, the NPI of the teaching anesthesiologist who started the case must be indicated in the appropriate field on the claim form.  The teaching anesthesiologist should use the AA modifier and the GC certification modifier to report such cases.  See 50 B. and 0 K.  5. Endoscopy Procedures   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