Chapter 15016

Office of Compliance

Medicare Carrier's Manual § 15016
Supervising Physicians In Teaching Settings

A.    Definitions

For purposes of this section, the following definitions apply:

Resident means 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 fiscal intermediary.

The fact that an individual hospital does not choose to include an eligible individual in its full-time equivalency count of residents does not change that individual's status as a resident in an approved GME program.

A medical student is never considered to be a resident. Any contribution of a medical student to the performance of a service or billable procedure (other than taking the history of a case in E/M service) must be performed in the physical presence of a physician or jointly with a resident in a service meeting the requirements set forth below for teaching physician billing.

Teaching Physician means a physician (other than another resident) who involves residents in the care of his or her patients.

Direct Medical and Surgical Services means 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 fiscal intermediary for the hospital

Teaching Hospital means a hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry.

Teaching Setting means any provider, hospital-based provider, or non-provider setting in which Medicare payment for the services of residents is made by the fiscal intermediary under the direct graduate medical education payment methodology or freestanding SNF or HRA in which such payments are made on a reasonable cost basis.

Pay for physician services furnished in teaching setting under the physician fee schedule only if:

The services are personally furnished by a physician who is not a resident; or

The services are furnished jointly by a teaching physician and resident or by a resident in the presence of a teaching physician with certain exceptions as provided below.

In both situations, the services of the resident are payable through either the direct GME payment or reasonable cost payments made by the fiscal intermediary.

B.    Special Situations

If a resident participates in a service furnished in a teaching setting, pay for the services of a teaching physician under the physician fee schedule only if the teaching physician is present during the key portion of the service for which payment is sought.

1.    Evaluation and Management (E/M) Services:

For a given encounter, the selection of the appropriate level of E/M service should be based on "Documentation Guidelines for Evaluation and Management Services" developed by the American Medical Association (AMA) and HCFA and published by the AMA. If a teaching physician documents his or her presence and participation in the E/M service, the level of service may be selected based on the extent of history and/or examination and/or the complexity of the medical decision making required by the patient and documented in his or her personal entry in the medical record which may include references to notes entered by the resident.

Except as indicated in subsection 2, the teaching physician must be physically present during the portion of the service that determines the level of service billed. In all cases, the teaching physician must personally document his/her presence and participation in the services in the medical records. This documentation by the teaching physician may either be in writing or via a dictated note, and expressed in the following ways for these major categories of E/M service:
a.    Initial Hospital Care, Emergency Department Visits, Office Visits for-New Patients, Office Consultations, and Hospital Consultations:
A personal notation must be entered by the teaching physician documenting his or her participation in the 3 key components of these services (i.e., history, examination, and medical decision making) as required by CPT and demonstrating the appropriate level of service required by the patient. If the teaching physician is repeating key elements of the service components obtained previously and documented by the resident, e.g., the patient's complete history and physical examination, the teaching physician need not repeat the documentation of these components in detail. Rather, the documentation of the teaching physician may be brief, summary comments that relate to the resident's entry and which confirm or revise the key elements defined for the purpose of this section as:

Relevant history of present illness and prior diagnostic tests;

Major finding(s) of the physical examination;

Assessment, clinical impression or diagnosis; and

Plan of care.

Therefore, the documentation of the key elements above may be satisfied by the combination of entries into the medical record made by the resident and the teaching physician. The documentation requirements for some common clinical situations for teaching physicians are illustrated below:

(1)    Illustration 1-All required elements are obtained personally by the teaching physician without a resident present. In this situation, a resident may or may not have performed an independent service.

If no resident has seen the patient, the physician should document on the same basis he or she would document an E/M service in a nonteaching setting.

If a teaching physician's service follows a resident's service, then the teaching physician's documentation should refer to the resident's note and provide summary comments that establish, revise, or confirm the resident's findings and the appropriate level of service required by the patient. For example, the teaching physician would not have to restate the review of systems and family social history in the case of an initial hospital service. However, the teaching physician would have to examine and question the beneficiary to verify the key findings of the resident's notes since he or she was not present during the resident's interaction with the beneficiary.

(2)    Illustration 2- All required elements are obtained by the resident in the presence of, or jointly with, the teaching physician and documented by the resident. In this situation, the resident's note may document the teaching physician's direct observation, performance, and personal input into the key elements. The teaching physician's personal documentation may be limited. At a minimum, it must include a confirmation of each component of the resident's documentation and teaching physician's presence during the service. The combination of entries must be adequate to substantiate the level of service required by the patient.

(3)    Illustration 3- Selected required elements of the service, for example, history and physical examination are obtained by the resident independently. The teaching physician repeats the key elements of the examination. These elements are discussed with the teaching physician either prior to or after the teaching physician's personal service. In this situation, the resident's note may document the teaching physician's input into the history and medical decision-making. The teaching physician's note must include summary comments that revise or confirm the findings of the resident's physical examination and discussion of the history of medical decision-making. The combined entries must be adequate to substantiate the level of service required by the patient and billed.

b.    Subsequent Hospital Care and, Office Visits - Established Patient:

A personal notation by the teaching physician must be entered highlighting 2 of the 3 key components of these services (i.e., history, physical examination, and medical decision-making). The same guidelines set forth in a. are required for follow-up visits for established patients.

For E/M codes that are selected on the basis of time, see subsection 7 below.
2.    Exception: E/M Services Furnished in Certain Primary Care Centers --
For E/M codes listed below, pay teaching physician claims for service furnished by residents without the presence of a teaching physician. When a GME program is granted the primary care exception, it applies to the following lower and mid-level E/M service:

New Patient Established Patient

99201 99211

99202 99212

99203 99213

For this exception to apply, a center must attest in writing that all of the following conditions are met for a particular residency program. A center does not have to be approved in advance. Maintain a file of such attestations for later use in the case of questionable future claims for payment.

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 fiscal intermediary. 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 fiscal intermediary that the entity meets the requirements of a written agreement between the hospital and the entity set forth in 42CRF 413.86(f)(1)(iii).

Any resident furnishing the service without the presence of a teaching physician must have completed more than 6 months of an approved residency program. If it becomes necessary to verify this information, teaching hospitals are required to maintain such information under the provisions of 42 CRF 413.86(f)(2).

The teaching physician in whose name the payment is sought must not supervise more than 4 residents at any given time and must direct the care from such proximity as to constitute immediate availability. The teaching physician must:

Have no other responsibilities at the time of the service for which payment is sought;

Assume management responsibility for those beneficiaries seen by the residents;

Ensure that the services furnished are appropriate;

Review with each resident during or immediately after each visit, the beneficiary's medical history, physical examination, diagnosis, and record of tests and therapies; and

Document the extent of his or her own participation in the review and direction of the services furnished to each beneficiary.

The patients seen must be an identifiable group of individuals who consider the center to be the continuing source of their health care and in which services are furnished by residents under the medical direction of teaching physicians. The residents must generally follow the same group of patients throughout the course of their residency program, but there is no requirement that the teaching physicians remain the same over any period of time.

The range of services furnished by residents includes all of the following:

Acute care for undifferentiated problems or chronic care for ongoing     conditions including chronic mental illness;

Coordination of care furnished by other physicians and providers;

Comprehensive care not limited by organ system or diagnosis.

The types of residency programs most likely to quality for the primary care 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.
3.    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 post-operative 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 key or critical portions of the procedure. The teaching surgeon may determine which post-operative visits are to be considered key and require his or her presence. However, if the post-operative period extends beyond the beneficiary's discharge and the teaching surgeon is not going to be involved in the beneficiary's follow-up care, the instructions on billing for less than the global package in section 4824.B. apply. During the period in which the teaching surgeon does not have to be physically present, he or she must remain immediately available to return to the procedure, i.e., he or she must not be involved in another procedure from which he or she cannot return. During the period in which the teaching surgeon does not have to be physically present, he or she must arrange for another physician to be immediately available to intervene in the original case should the need arise in order to bill for the original procedure. The designee would be a physician who is not involved in or immediately available for any other surgical procedure. HCFA is not defining availability in terms of geographic location vis-à-vis the operating room.
1.    Single surgery -- When the teaching surgeon is present for the entire period between the opening and closing of the surgical field, 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 for two overlapping surgeries, the teaching surgeon must be present during the key portions of both operations. Therefore, the 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 the key portion of both procedures in his or her notes in order that a reviewer may clearly infer that the teaching physician was immediately available to return to the procedure in the event of complications. If the teaching physician leaves the operating room after the key portion(s) of the surgical procedure or during the closing of the surgical field to become involved in another surgical procedure, he or she must arrange for another physician to be immediately available to intervene in the original case should the need arise in order to bill for the original procedure. In the case of three concurrent surgical procedures, the role of the teaching surgeon (but not the anesthesiologist) in each of the cases is classified as a supervisory service to the hospital rather than a physician service to an individual beneficiary and is not payable under the physician fee schedule.

b.    Minor procedures --
For procedures that take only a few minutes (5 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.
c.     Anesthesia-Pay --
An unreduced fee schedule payment if a teaching anesthesiologist is involved in a procedure with one resident. The teaching physician must document in the medical records that he or she was present during all critical (or key) portions of the procedure including induction and emergence. The teaching physician's presence is not required during the preoperative or post-operative visits with the beneficiary. If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a nonphysician anesthetist, pay for the anesthesiologist's services as medical direction.
d.    Endoscopy Procedures --
In order to bill for procedures performed through an endoscope (other than endoscopic operations that follow the surgery policy in subsection a), the teaching physician must be present during the entire viewing. The entire viewing includes insertion and removal of the device. Viewing of the entire procedure through a monitor in another room does not meet the teaching physician presence requirement.

4. Interpretation of Diagnostic Radiology and Other Diagnostic Tests --
Pay for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed or reviewed by a physician other than a resident. If the teaching physician's signature is the only signature on the interpretation, you may assume that he or she is indicating that he or she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the image and the resident's interpretation and either agrees with it or edits the findings. Do not pay for an interpretation if the documentation shows simply a countersignature of the resident's interpretation by the teaching physician.

5. Psychiatry --
For psychiatric services furnished under an approved GME program, 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 meet this exception to the physical presence requirement. In the case of time-based services such as individual medical psychotherapy see section 7, 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 program.

6. Time-Based Codes --

For procedure codes determined n the basis of time, the teaching physician must be present for the period of time for which the claim is made. For example, pay for a code that specifically describes a service of from 20 to 30 minutes only if the teaching physician is 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 G0071-G0094)

Critical care services (CPT 99291-99292)

Hospital discharge day management (CPT codes 99238-99239)

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.

Prolonged service (CPT codes 99358-99359), and

Care plan oversight (HCPCS codes G0064-G0065)

7. Other Complex or High-Risk Procedures --
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

Transesophageal echocardiography

8. Miscellaneous --

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 you 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.

Do not apply the physician presence policy to renal dialysis services of physicians who are paid under the physician monthly capitation payment method.

C.    Note: Subsection C of Section 15016 has been intentionally omitted

D.    Assistant at Surgery Services Furnished in Teaching Hospitals

1.    General --

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 D3, D4, or D5 are met. Each teaching hospital has a different situation concerning numbers of residents, qualifications of residents, duties of residents, and types of surgeries performed. There may be some teaching hospitals in which you 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 here 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. The carrier can 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 modifer-82, which indicates a qualified resident surgeon is not available. This certification is for use only when the basis for payment is the unavailability of qualified residents.

"I understand that section 1842(b)(7)(D) of the Social Security Act 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 Medicare carrier."

Retain the claim and certification for four years and conduct post-payment reviews as necessary. For example, investigate situations in which it is certified that there are never any qualified residents available and undertake recovery if warranted.

Assistant at surgery claims denied on the basis of these instructions do not qualify for payment under the waiver of liability provision.

2.    Definition --
An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure. 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.

3.    Exceptional Circumstances --

Payment may be made for the services of assistants at surgery in teaching hospitals, subject to the special limitation in section 15044, not withstanding 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 your medical staff may find that exceptional medical circumstances justify the services of a physician assistant at surgery even though a qualified resident is available.

4.    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 special limitation in section 15044, 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 nonteaching hospital. However, if the assistant is not a physician primarily engaged in the field of surgery, no payment may be made unless either of the criteria of subsection 5 is met.

5.    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. If payment is made on the basis of a single team fee, deny additional claims. Determine which procedures performed in your service area require a team approach to surgery. Team surgery is paid for on a "By Report" basis.

There are some situations when the services of physicians of different specialties are necessary during and when each specialist is required to play an active role in the patient's treatment because of the existence of more than one medical condition requiring diverse, specialized medical services. For example, a patient's cardiac condition may require the cardiologist be present to monitor the patient's condition during abdominal surgery. In this type of situation, the physician furnishing the concurrent care is functioning at a different level than that of an assistant at surgery, and payment is made on a regular fee schedule basis.

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