Basic Teaching Physician Presence and Documentation

Basic Teaching Physician Presence and Documentation Welcome to the Children s University Medical Group (CUMG) training on the Teaching Physician Presence and Documentation. The goal of this module is to assure your understanding of the governmental requirements for billing in a Teaching Setting. Once you have reviewed the content of this module, we want you to be able to identify: 1. When the Teaching Physician rules apply; 2. Where the Teaching Physician rules apply; and 3. What the Documentation requirements are for Teaching Physicians. It is important that you complete this module in its entirety. At the end of the module, you will be asked to take a Knowledge Assessment. Refer to the instructions on the CUMG New Provider Compliance web page where you will submit your responses. Once submitted, Compliance will confirm your training is complete. NOTE: CUMG is unable to bill for your patient services if you have not completed Compliance training. 1

CMS Teaching Physician Rules CUMG physicians comply with the presence standards described by the Centers for Medicare and Medicaid Services (CMS) guidance on Supervising Physicians in Teaching Settings, as revised on October 10, 2006, and as amended from time to time. These rules apply to services provided to all patients covered by federal funding, i.e. Medicare, Medicaid and Tricare. CUMG physicians also comply with the Documentation standards set forth in the CMS Teaching Physician Rules for all other services and patient encounters. In general, if a Resident participates in a service provided in a Teaching Setting, the Teaching Physician may bill for services when the Teaching Physician is present during, or personally performs, the key portion of any service for which payment is sought. See examples of exceptions to this rule described in this training module. These Documentation rules do not apply to: Advanced Practice Providers (APP) or non-physician practitioners when they work with Residents, and Shared work between Teaching Physicians and Advanced Practice Providers, i.e. ARNPs and PAs. General Presence Standard CUMG submits charges for physician services in the Teaching Setting only when those services have been properly documented as described below: 1. The services are personally furnished by a physician who is not a Resident; 2. A Teaching Physician was physically present during the Critical or Key Portions of the service that a Resident performs, subject to the exceptions (noted later in this module); or 3. A Teaching Physician provides care in a Primary Care Center, in accordance with the conditions required by CMS. **NOTE: If a Student/Resident/Fellow is present, even if it is only as an observer, the Teaching Physician is still required to personally insert a presence statement in the first person per CUMG policy. 2

Please review the following CUMG Policies for further guidance: Teaching Physician Presence and Documentation for Evaluation and Management Services Teaching Physician Presence and Documentation for Diagnostic Services Teaching Physician Presence and Documentation for Surgery and Procedure Services. Teaching Physician Services in Primary Care Centers CUMG Compliance Policies and Procedures can be found on the Seattle Children's Intranet webpage: http://child.childrens.sea.kids/policies_and_standards/policies_and_procedures/cumg.aspx Definitions Advanced Practice Provider (APP) : An individual who is not a physician, who is qualified by education, training, licensure/regulation and performs a professional service within his or her scope of practice and independently reports that professional service. Billable Fellows: Those who are not in GME approved programs, and who have faculty appointments to bill for their own services and are not Residents for purposes of this guidance. These providers are also referred to as acting Instructors. Critical and Key Portions: That part (or parts) of a service that the Teaching Physician determines is (are) a critical or key portion(s). This is determined at the discretion of the Teaching Physician and not defined by regulation. Documentation: Supports the presence of the Teaching Physician in very clear words, not the status of the Teaching Physician. Macro: A command in a computer or dictation application that automatically generates predetermined text that is not edited by the user. It is acceptable for the Teaching Physician to use a macro in an electronic medical record as the required personal Documentation IF the Teaching Physician adds it personally in a secured (password protected) system. 3

In addition to the Teaching Physician s macro, either the Resident or the Teaching Physician must provide customized information that is sufficient to support a medical necessity determination. It is insufficient for both the Resident and the Teaching Physician to document with macros only. Resident: An individual who participates in an approved Graduate Medical Education (GME) program. The term includes interns, Residents, and Fellows in GME programs recognized as approved for purposes of direct GME payments made by the CMS fiscal intermediary. 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. Teaching Hospital: A hospital engaged in an approved GME Residency Program in medicine, osteopathy, dentistry, or podiatry. Teaching Physician: A physician (other than another Resident or Accreditation Council for Graduate Medical Education (ACGME) Fellow who involves Residents or ACGME Fellows in the care of his or her patients. Teaching Setting: Any facility, hospital-based facility, or non-physician facility in which Medicare payment for the services of Residents is made by the fiscal intermediary under the direct graduate medical education payment methodology or a freestanding skilled nursing facility or home health agency in which such payments are made on a reasonable cost basis. Evaluation and Management Services The selection of the appropriate Evaluation and Management (E/M) service should be determined according to the American Medical Association's Current Procedural Terminology (CPT) manual. Supporting Documentation will determine E/M level according to the 1995 Documentation Guidelines for Evaluation and Management Services or the 1997 Documentation Guidelines for Evaluation and Management Services whichever is most advantageous to the provider. 4

To bill E/M services, the Teaching Physician must personally document at a minimum the following: 1. That the Teaching Physician performed the service or was physically present during the Critical or Key Portions of the service while a Resident performed the services; and 2. That the Teaching Physician participated in the management of the patient. a. Documentation by the Resident of the presence and participation of the Teaching Physician is not sufficient to establish the presence and participation of the Teaching Physician. b. The combined entries into the medical record by the Teaching Physician and the Resident make up the Documentation for the level of service and together must support the medical necessity of the service. If the Resident provides the service without the Teaching Physician s direct participation, the Resident must document the note, and the service cannot be billed. Sample Scenarios The following three common scenarios are for Teaching Physicians providing E/M services with examples of the minimum requirements for Documentation in each scenario. Scenario 1 The Teaching Physician personally performs all the required elements of an E/M service without a Resident. The Resident may or may not have performed the E/M service independently. 1. In the absence of a note by a Resident, the Teaching Physician must document as they would an E/M service in a non-teaching Setting. 2. Where a Resident has written notes, the Teaching Physician's note may reference the Resident's note. 5

a. The Teaching Physician must document that they performed the critical or key portion(s) of the service and were directly involved in the management of the patient. b. The combination 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. Examples: Admitting Note: "I performed a history and physical examination of the patient and discussed his management with the Resident. I reviewed the Resident's note and agree with the documented findings and plan of care. Follow-up Visit: Hospital Day #3. "I saw and evaluated the patient. I agree with the Resident's note as documented. Follow-up Visit: Hospital Day #5. "I saw and examined the patient. I agree with the Resident's note except the heart murmur is louder, so I will obtain an echo to evaluate. Scenario 2 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. 1. In this case, the Teaching Physician must document that they were present during the performance of the critical or key portion(s) of the service and were directly involved in the management of the patient. 2. The Teaching Physician's note should reference the Resident's note. The combination 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. 6

Examples: Initial or Follow-up Visit: "I was present with Resident during the history and exam. I discussed the case with the Resident and agree with Documentation in the Resident's note. Follow-up Visit: "I saw the patient with the Resident and agree with the Resident's Documentation. Scenario 3 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. 1. In this instance, the Teaching Physician must document that he/she personally saw the patient, personally performed the critical or key portion(s) of the service, and participated in the management of the patient. 2. The Teaching Physician's note should reference the Resident's note. The combination 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. Examples: Initial Visit: "I saw and evaluated the patient. I reviewed the Resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs. Initial or Follow-up Visit: "I saw and evaluated the patient. Discussed with Resident and agree with Resident's findings and plan as documented in the Resident's note. Follow-up Visit: "See Resident's note for details. I saw and evaluated the patient and agree with the Resident's finding and plans as written. Follow-up Visit: "I saw and evaluated the patient. Agree with Resident's note but lower extremities are weaker, now 3/5; MRI of L/S Spine today. 7

Unacceptable Documentation The following are examples of unacceptable Documentation: "Agree with above.", followed by legible countersignature or identity; "Rounded, Reviewed, Agree.", followed by legible countersignature or identity; "Discussed with Resident. Agree.", followed by legible countersignature or identity; "Seen and agree.", followed by legible countersignature or identity; "Patient seen and evaluated.", followed by legible countersignature or identity; and A legible countersignature or identity alone. The above examples are NOT ACCEPTABLE because the Documentation does not make it clear whether the Teaching Physician was present, evaluated the patient and/or had any involvement with the plan of care. Exception for E/M Services Furnished in Certain Primary Care Centers There are instances when Teaching Physicians may bill for lower and mid-level E/M services provided by Residents without the physical presence of a Teaching Physician. This is known as the Primary Care Exception Rule. When a GME program is granted a primary care exception (PCE), this rule may apply. CUMG must satisfy the CMS criteria for any location seeking primary care center exception status. Examples of CUMG staffed clinics that meet the PCE are Odessa Brown and Roosevelt Pediatric clinic. Teaching Physicians may submit claims for the following codes for services furnished by Residents in the absence of a Teaching Physician in the PCE clinics. New Patient: 99201, 99202, 99203 Established Patient: 99211, 99212, 99213 Initial Comprehensive Preventive Medicine: 99381-99385 Periodic Comprehensive Preventive Medicine: 99391-99395 Initial and Annual Wellness visits: G0402, G0438 and G0439. 8

For all other services in the PCE center, the General Presence Standard of the Teaching Physician Policy applies. See the requirements above regarding Teaching Physician Rules for Evaluation and Management Services. Primary Care Centers Exception Under the PCE, 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. Teaching Physicians submitting claims under this exception may not supervise more than four Residents at any given time and must be immediately available to assist the Resident, if needed. The Teaching Physician MUST: 1. Not have other responsibilities (including the supervision of other personnel) at the time the service was provided by the Resident; 2. Have the primary medical responsibility for patients cared for by the Residents; 3. Ensure that the care provided was reasonable and necessary; 4. 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 5. Document the extent of their participation in the review and direction of the services furnished to each patient. Example of PCE Teaching Statements: Pediatric Preventive Services were provided under my personal supervision and I was physically present in the clinic at that time. I have personally reviewed this visit, on the same day of the visit, with the Resident performing the direct patient care, I agree with the diagnosis(es) and treatment plan(s) listed below. 9

Patients cared for under this exception should consider the center to be their primary location for healthcare 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. CMS Teaching Physician Rules E/M Service Documentation Provided By Medical Students Teaching Physician rules do not apply to Students. The Teaching Physician may not refer to a Student's Documentation of the history of present illness, physical exam findings or medical decision-making for billing purposes. Contributions to or participation in the performance of a billable service (other than the review of systems and/or past/family/social history) by a Student must be performed in the physical presence of a Teaching Physician or physical presence of a Resident in a service meeting the requirements for Teaching Physician billing. Students may document services in the medical record. However, the Teaching Physician may not link to any Student Documentation of an E/M service except for Documentation related to the review of systems (ROS) and/or past/family/social history (PFSH.) The Teaching Physician may not refer to a Student's Documentation of the History of Present Illness (HPI), physical exam findings or medical decisionmaking (MDM) in their personal note. If the medical Student documents E/M services, the Teaching Physician performs and re-documents the physical exam and medical decision making activities of the service. Services documented by a Student and cosigned by the Resident cannot be used by a Teaching Physician for billing purposes. 10

Example Question If the Resident I m working with agrees with an excellent note written by a Medical Student, can I then agree with the Resident s note that uses some Medical Student s Documentation? Answer NO -The only Medical Student Documentation that can be used is ROS, PFSH, and vital signs. If your Resident has linked to a Medical Student s note, only the ROS, PFSH and vital signs will be counted from the Medical Student Documentation. If the Resident has not fully documented the rest of the encounter, you will not have a billable encounter unless you have performed and re-documented the missing portion. Services Provided by Billable Fellows/Acting Professors Excerpt taken from the CUMG Policy on E/M Teaching Physician Presence Documentation: Individuals who are not in an approved GME program and who are licensed to practice in multiple settings are not Residents. The Teaching Physician cannot bill for supervision of these individuals or link to the notes of these individuals as if they were Residents. Surgical, High-Risk, or Other Complex Procedures Minor Surgical Procedures: For procedures that take only a few minutes (5 minutes or less) or designated as minor procedures by CMS and involve relatively little decision making once the need for the operation is determined, the Teaching Physician must be present for the entire procedure in order to bill for the procedure. If the Teaching Physician personally performs the entire procedure without a Resident present and personally documents his or her own procedure note, a separate presence 11

statement is not required and the Teaching Physician would document on the same basis as a service provided in a non-teaching Setting. When a Resident is involved, the Teaching Physician must document his or her presence or participation in the procedure. If the Teaching Physician is not present for the entire procedure, the procedure will not be billed. The Documentation must state: I performed the entire procedure. OR I was present for the entire procedure, which was performed under my personal supervision. Major 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. **NOTE: If the Teaching Physician personally performs the entire procedure without a Resident present and personally documents his or her own procedure note, a separate presence statement is not required as part of the Documentation. For example, it is not necessary to state, I performed the entire procedure. when no Resident was present during the service. Other Complex or High-Risk Procedures In the case of complex or high-risk procedures for which CMS policy, or the CPT description indicate that the procedure requires personal (in person) supervision of its performance by a physician, the Teaching Physician must be present throughout the procedure that is billed. The presence of the Resident alone is not sufficient. The Teaching Physician must document their presence or participation in the procedure. These procedures include: 12

Interventional radiology; Cardiology supervision and interpretation codes; Cardiac catheterization; Cardiovascular stress tests; and Transesophageal echocardiography (TEE). Surgery The Teaching Surgeon is responsible for the pre-operative, operative, and postoperative care of the patient. The Teaching Surgeon's presence is not required during the opening and closing of the surgical field unless these activities are considered to be the Critical or Key Portion(s) of the procedure. The Teaching Surgeon determines which post-operative visits are considered critical or key and require their presence. During non-critical or non-key portions of the surgery, if the Teaching Surgeon is not physically present, they must be immediately available to return to the procedure, i.e., they cannot be performing another procedure. If the Teaching Physician is not immediately available, they must arrange for another qualified surgeon to be immediately available to assist with the procedure if needed. The Teaching Physician must include a statement identifying the physician considered to be immediately available. The physician identified as immediately available cannot be engaged in another procedure. Two Overlapping Surgeries For overlapping surgeries, the Teaching Physician must be present during the Critical or Key Portions of both operations; therefore, the Critical or Key Portions cannot take place at the same time. When all of the key portions of the initial procedure have been completed, the Teaching Physician may begin to become involved in a second procedure. In the case of three concurrent surgical procedures, the role of the Teaching Surgeon (but not Teaching Anesthesiologist) in each of the cases is classified as a supervisory 13

service to the hospital. These services may not be billed as a physician service. The Documentation must state: I was present for or participated in the Critical or Key Portion(s) of the procedure(s) and I was immediately available for the remainder of the procedure(s). OR I was present for or participated in the Critical or Key Portion(s) and (provide the name of another qualified CUMG Teaching Physician) was immediately available for the remainder of the procedure(s). Endoscopy Procedures For endoscopic procedures, Medicare has determined that the Key or Critical Portion is the time from insertion of the scope to removal of the scope. Therefore 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. The Teaching Physicians must document their presence or participation in the procedure. Time-Based Codes For procedure codes determined on the basis of time, the Teaching Physician must be present for the entire period of time for which the claim is made. For example, CUMG bills for a service of 30 minutes only if the Teaching Physician is present for the entire 30 minutes. Once a time statement is documented, time then becomes the sole criteria for the selection of the level of service. 14

Outpatient/Office visit Total time in the clinic is defined as face-to-face time spent by the billing provider. 1. Services provided before the patient is seen or after the patient leaves the clinic are not counted towards the time component. 2. The outpatient rule for face-to-face time should not be confused with the ability to provide counseling or coordination of care services with the family or caregiver, in the absence of the patient. Common examples would be; patient does not have the ability to make decisions, patient is unable to provide history, or, the parents have requested a separate meeting to discuss issues privately, without the minor in the room. In these cases, the medical necessity of the service being provided without the patient being present must be clearly documented. 3. Do not add time spent by the Resident in the absence of the Teaching Physician to: a. Time spent by the Resident and Teaching Physician with the patient or b. Time spent by the Teaching Physician alone with the patient. Inpatient visit Total time is defined as Unit/floor time for hospital services and is time on the unit/floor and at the bedside. This includes: Establishing or reviewing the chart; Writing notes and orders; and Coordination of care with other providers. This time need not be continuous but it must be related to the same patient. Codes falling into this category include: Individual medical psychotherapy; Hourly critical care services; Hospital discharge day management; E/M codes in which counseling and/or coordination of care dominates more than 50 percent of the encounter (Time is considered the key or controlling factor for this level of E/M service.) 15

Prolonged physician services. (These codes are based on total time, above the normal threshold of the base service.) Click here to go to Assessment 16