Source: https://www.compliance.cumc.columbia.edu/compliance-standards/physicians-teaching-hospitals-path-regulations
Timestamp: 2018-03-19 14:48:16
Document Index: 308425359

Matched Legal Cases: ['§100', '§100', '§100', '§40', '§50', '§0', '§100', '§100', '§100', '§1842', '§20', '§20', '§20']

Physicians at Teaching Hospitals (PATH) Regulations | CUMC Billing Compliance
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Physicians at Teaching Hospitals (PATH) Regulations
Evaluation and Management (E&M) Guidelines
Centers for Medicare /Medicaid Services(CMS)
(Rev. 811, Issued: 01-13-06, Effective: 01-01-06, Implementation: 02-13-06)
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 programs 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 payments 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 physician 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.
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
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. 2303, Issued: 09-14-11, Effective: 06-01-11, Implementation: 07-26-11)
A. General Documentation Instructions and Common Scenarios
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 Association’s Current Procedural Terminology (CPT) and any applicable documentation guidelines.
The teaching physician personally performs all the required elements of an E/M service without a resident. In this scenario the resident may or may not have performed the E/M service independently.
In the absence of a note by a resident, the teaching physician must document as he/she would document an E/M service in a non-teaching setting.
Where a resident has written notes, the teaching physician’s note may reference the resident’s note. The teaching physician must document that he/she performed the critical or key portion(s) of the service, and that he/she was directly involved in the management of the patient. 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.
The resident performs the elements required for an E/M service in the presence of, or jointly with, the teaching physician and the resident documents the service. In this case, the teaching physician must document that he/she was present during the performance of the critical or key portion(s) of the service and that he/she was directly involved 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 and the level of the service billed by the teaching physician.
The resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his/her service. The teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident. In this instance, 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.
•The teaching physician must document that he/she personally saw the patient and participated in the management of the patient. The teaching physician may reference the resident's note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient's condition has not changed, and the teaching physician agrees with the resident's note.
•The teaching physician's note must reflect changes in the patient's condition and clinical course that require that the resident's note be amended with further information to address the patient’s condition and course at the time the patient is seen personally by the teaching physician.
•The teaching physician’s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making regardless of whether the combination of the teaching physician’s and resident’s documentation satisfies criteria for a higher level of service. 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.
Following are examples of minimally acceptable documentation for each of these scenarios:
(NOTE:In this scenario if there are no resident notes, the teaching physician must document as he/she would document an E/M service in a non-teaching setting.)
Initial or Follow-up Visit: “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”
“Patient seen and evaluated.”, followed by legible countersignature or identity; and
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.
Students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the medical student documents E/M services, the teaching physician must verify and re-document the history of present illness as well as perform and re-document the physical exam and medical decision making activities of the service.
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.
For the E/M codes listed below, teaching physicians may submit claims for services furnished by residents in the absence of a teaching physician:
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 particular 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 hospital’s A/B MAC (A). This requirement is not met when the resident is assigned to a physician’s 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 CFR413.78(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 provisions 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 less than 6 months in a GME approved residency program in the mix of four residents under the teaching physician’s 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 resident;
•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 resident during or immediately after each visit. This must include a review of the patient’s medical history, the resident’s findings on physical examination, the patient’s diagnosis, and treatment plan (i.e., record of tests and therapies); and
•Document the extent of his/her own participation in the review and direction of the services furnished to each patient.
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.
100.1.2- Surgical Procedures
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 physician’s presence is not required during the opening and closing of the surgical field unless these activities are considered to 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 patient’s discharge and the teaching surgeon is not providing the patient’s 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 immediately 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.
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.
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 physician’s 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 non-physician anesthetist and the service is furnished prior to January 1, 2010, Medicare pays for the anesthesiologist’s 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 present 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 anesthesiologist 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.
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.
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.
100.1.3- Psychiatry
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 presence 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
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 falling into this category include:
Individual medical psychotherapy (HCPCS codes 90804 -90829);
Hospital discharge day management (CPT codes 9923899239);
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;
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 physician’s 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 teaching MCP physician is physically present during the visit. The teaching physician may utilize the resident’s 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 reviewed the resident’s 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
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 service 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 program 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 certify 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.
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.
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 physician 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 postoperative care of his or her patients. Generally, this exception is applied to community physicians who have no involvement in the hospital’s GME program. In such situations, payment may be made for reasonable and necessary services on the same basis as would be the case in a non-teaching 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 procedure. 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 denied. 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.
100.1.8- Physician Billing in the Teaching Setting
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 exception must include the GE modifier on the claim for each service furnished under the primary care center exception.
100.2- Interns and Residents
B3-2020.8, B3-8030
An attending physician’s services to beneficiaries in a teaching setting are covered under the supplementary medical insurance program. Many physicians rendering such services are on the faculty of a medical school or have arrangements with providers to supervise and teach interns and residents. Payment may be made for professional services to a beneficiary by an “attending” physician where the attending physician provides personal identifiable direction to interns or residents who are participating in the care of this patient.
See the Medicare Benefit Policy Manual, Chapter 15, for services furnished by interns and residents within and outside the scope of an approved training program.