(Medicare Claims Processing Manual)

90.6 - The Indian Health Service (IHS) Provider Payment to Non -IHS Physicians for Teleradiology Interpretations  (Rev. 1643, Issued: 12- 05-08, Effective: 01 -01-07, Implementation: 03- 09-09)  The IHS providers may choose to purchase or otherwise contract with non- IHS physicians or practitioners for teleradiology interpretations services.  These services may be paid using either contractual reassignment or purchased test methodologies.  See Chap ter 19, Section 120 of this Manual for further information.  90.7 - Bundling of Payments for Services Provided in Wholly Owned and Wholly Operated Entities (including Physician Practices and Clinics): 3- Day Payment Window  (Rev. 2373, Issued: 12- 21-11, Effective: 01 -01-12, Implementation: 01- 03-12)  In accordance with section 102(a)(1) of the PACMBPRA, for outpatient services furnished on or after June 25, 2010, the technical portion of all nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are deemed related to the admission and thus, must be included on the bill for the inpatient stay. Also, the technical portion of outpatient nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second,  and  the third  calendar days (1 calendar day for a nonsubsec tion (d) hospital) immediately preceding the date of admission are deemed related to the admission and, therefore, must be billed with the inpatient stay, unless the nondiagnostic services are unrelated to the inpatient hospital claim (that is, the preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiarys inpatient admission).  In such cases, the unrelated outpatient hospital nondiagnostic services are covered by Medicare Part B, and the hospital or wholly owned or wholly operated physician practice shall include the technical portion of the services in their billing. PACMBPRA did not change the requirement that the technical portion of all diagnostic services provided by the hospital (or entity wholly owned or wholly operated by the hospital) occurring on the date of an inpatient admission, or during the 3 calendar days (or 1 calendar day) immediately preceding the date of an inpatient admission must be billed with the inpatient admission.   Implementation of the 3 -day Payment Window Policy in Wholly Owned or Operated Entities   Wholly owned or wholly operated entities are subject to the 3- day (or 1- day) payment window policy when they furnish preadmission diagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding1 calendar day), or when they furnish preadmission nondiagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding 1 calendar day) for related medical care. Only unre lated nondiagnostic preadmission services are not subject to the payment window policy, where unrelated preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiary's inpatient admission and are furnished on the 1st, 2nd, or 3rd calendar day immediately preceding the date of the inpatient admission. (Note: nondiagnostic services furnished by a wholly owned or wholly operated physician practice on the date of a beneficiarys inpatient admission to the hospita l are always deemed to be related to the admission and their technical portion must be included on the bill for the inpatient admission.) When an entity that is wholly owned or wholly operated by a hospital furnishes a service subject to the 3- day window policy, Medicare will pay the professional component of services with payment rates that include a professional and technical split and at the facility rate for services that do not have a professional and technical split. Once the entity has received confi rmation of a beneficiarys inpatient admission from the admitting hospital, they shall, for services furnished during the three -day window,  append a CMS payment modifier to all claim lines for diagnostic services and for those nondiagnostic services that have been identified as related to the inpatient stay.   Physician nondiagnostic services that are unrelated to the hospital admission are not subject to the payment window and shall be billed without the payment modifier.   Definition of Wholly Owned or Wholly Operated Entities   Wholly owned or wholly operated entities are defined in 42 CFR 412.2; "An entity is wholly owned by the hospital if the hospital is the sole owner of the entity. And, an entity is wholly operated by a hospital if the hospital has exclusive responsibilit y for conducting and overseeing the entitys routine operations, regardless of whether the hospital also has policymaking authority over the entity."   90.7.1 - Payment Methodology: 3 -Day Payment Window in Wholly Owned or Wholly Operated Entities (including Physician Practices and Clinics)  (Rev. 2373, Issued: 12- 21-11, Effective: 01 -01-12, Implementation: 01- 03-12)  CMS has established HCPCS payment modifier PD (Diagnostic or related nondiagnostic item or service provided in a wholly owned or operated physician office to a patient who is admitted as an inpatient within 3 days), and requires that the modifier be appended to the physician preadmission diagnostic and admission- related nondiagnostic services, reported with HCPCS/CPT codes, which are subject to the 3- day payment window polic y. The wholly owned or wholly operated physicians office will need to manage their billing processes to ensure that they bill for their physician services appropriately when a related inpatient admission has occurred.  The hospital is responsible for noti fying the practice of an inpatient admissions for a patient who received services in a wholly owned or wholly operated physician office within the 3- day (or, when appropriate,1- day) payment window prior to the inpatient stay.  The modifier is effective for  claims with dates of service on or after January  1, 2012. Wholly owned or wholly operated per their readiness to do so. Entities have the discretion to apply these policies for claims with dates of service on and after January 1, 2012, but shall comply wi th these polices no later than July 1. 2012.  When the modifier is present on claims for service CMS shall pay   only the Professional Component (PC) for CPT/HCPCS codes with a Technical Component (TC)/PC split that are provided in the 3- day (or, in the case of non -IPPS hospitals, 1- day) payment window, and    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 include d in the payment for the surgery. However, there may be times when the surgery itself is subject to the 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 the 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