NAMAS - Study the Rules Before Auditing E&M Services by Teaching Physicians

by  Find-A-Code
June 28th, 2016

If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ensure that your organization is reporting these services correctly. If this is an area you need to review, then Chapter 12 of the CMS Internet only manual, section 100.1 should become your best friend.

One area that requires great scrutiny is the documentation of the medial record. There should be proof of the teaching physician's presence and involvement in the documentation. For Evaluation and Management (E&M) services, it must be documented by the teaching physician to prove that he/she:

The combined documentation by both the resident and the teaching physician is used to determine the overall level of service, so you will need to make sure that both reports support the care that was provided. It is not considered supporting documentation if the resident simply reports the presence of the teaching physician and that he/she participated in the care, this must also be reported by the teaching physician. Chapter 12, section 100.1.1 of the Medicare Manual gives examples of scenarios for teaching physicians and what constitutes acceptable and unacceptable documentation of presence and participation.

When looking at documentation where time was used to report the level of service for an encounter that involves a resident, it is important to note that the level of service billed is based on the teaching physician's time presence. The time used for reporting does not include any time where only the resident was present with the patient. The teaching physician must be involved with the patient for the time reported in the code submitted for reimbursement.

If your organization has an approved Graduate Medical Education (GME) Program which has been granted a primary care exception, then residents of these organizations are permitted to bill lower and mid level E&M services. This includes 99201-99203 for new patients, 99211-99213 for established patients, G0402 for initial preventive physical exams and G0438/G0439 for annual wellness visits (first or subsequent). These services may be billed under the teaching physician without the physician's physical presence of the service. The teaching physician is performing a supervisory role and the direct supervision rules apply. In this scenario, direct supervision means that they may not supervise more than four residents at one time and must be immediately available among other direct supervision criteria. For services that are reported beyond those listed above, the regular teaching physician documentation requirements must be met. Therefore, if the resident is billing for the higher level E/M visits (99204, 99205, 99214 and 99215), then there needs to be documentation of the teaching physician's involvement in the care and participation in the management of the patient. If this documentation requirement has not been met, then a lower level of E&M service would need to be reported.

This tip is just a brief snapshot of some of the items you'll need to make yourself familiar with if residents and teaching physician work is part of your audit focus. There are rules around reporting for resident work in the surgical setting, anesthesia, diagnostic testing and others so make certain that if you are responsible for auditing these types of services that you familiarize yourself with the rules. The more you know about the intricacies of documentation requirements and billing for these services, the more successful your audits will be and the better you can assist your organization in mitigating any risk when these services are scrutinized by an outside reviewer. 

This Week's Audit Tip
Provided by:
Sara San Pedro, CPC, CEMC, CPMA

Sara is the Director of Quality Assurance for DoctorsManagement's Department of Audit and Regulatory Compliance

NAMAS - Study the Rules Before Auditing E&M Services by Teaching Physicians. (2016, June 28). Find-A-Code Articles. Retrieved from

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