(Medicare Claims Processing Manual)

 The facility rate for codes without a TC/PC split.   Global Surgical Services and the 3 -day Payment Window Policy  We note that the time frames associated with 10 and 90 day global surgical packages could overlap with the 3- day (or 1- day) payment window policy.   The 3- day payment window makes no change in billing surgical services according to global surgical rules, and pre - and post -operative services continue to be included in the payment for the surgery. However, there may be times when the surgery itself is subject to t he three- day window policy, as would occur if the surgery were performed within the three -day window.  For example, a patient could have a minor surgery in a wholly owned or wholly operated physician office and then, due to a complication, be admitted to t he hospital as an inpatient.  In such cases the modifier shall be appended to the appropriate surgical HCPCS/CPT code.   100 - Teaching Physician Services  (Rev. 811, Issued: 01- 13-06, Effective: 01 -01-06, Implementation: 02- 13-06) Definitions  For purposes of this section, the following definitions apply. Resident -  An individual who participates in an approved graduate medical education (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 program s recognized as approved for purposes of direct GME payments made by the FI.  Receiving 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 (e.g., a medical school) 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.  See 100.1.1B for a discussion concerning E/M service documentation performed by students. Teaching Physician -  A physician (other than another 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 making the reasonable cost election for physician services furnished in teaching hospitals.  All payments for such services are made by the A/B MAC (A) for the hospital.  Teaching Hospital -  A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry. Teaching Setting -  Any provider, hospital -based provider, or nonprovider setting in which Medicare payment for the services of residents is made by the A/B MAC (A) under the direct graduate medical education payment methodology or freestanding SNF or HHA in which such payme nts are made on a reasonable cost basis.  Critical or Key Portion  - That part (or parts) of a service that the teaching physician determines is (are) a critical or key portion(s).  For purposes of this section, these terms are interchangeable.  Documentation  - Notes recorded in the patient's medical records by a resident, and/or teaching physician or others as outlined in the specific situations below regarding the service furnished.  Documentation may be dictated and typed or hand -written, or computer -generated and typed or handwritten.  Documentation must be dated and include a legible signature or identity.  Pursuant to 42 CFR 415.172 (b), documentation must identify, at a minimum, the service furnished, the participation of the teaching physic ian in providing the service, and whether the teaching physician was physically present.  In the context of an electronic medical record, the term 'macro' means a command in a computer or dictation application that automatically generates predetermined text that is not edited by the user.  When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation if the teaching physician adds it personally in a secured (password protected) system.  In addition to the teaching physicians 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.  It is insufficient documentation if both the resident and the teaching physician use macros only.  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.  100.1 - Payment for Physician Services in Teaching Settings Under the MPFS  (Rev. 811, Issued: 01- 13-06, Effective: 01 -01-06, Implementation: 02- 13-06) Pursuant to 42 CFR 415.170, services furnished in teaching settings are paid under the physician fee schedule if the services are:   Personally furnished by a physician who is not a resident;   Furnished by a resident where a teaching physician was physically present during the critical or key portions of the service; or   Certain E/M services furnished by a resident under the conditions contained in 100.01.C. In all situations, the services of the resident are payable through either the direct GME payment or reasonable cost payments made by the A/B MAC (A) .  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)