Teaching physician rules

1. Teaching physician rules Jeffrey Linzer Sr., MD, MICP, FAAP, FACEP Associate Medical Director for Business Affairs & Compliance Emergency Pediatric Group Children’s Healthcare of Atlanta at Egleston & Hughes Spalding Assistant Professor of Pediatrics and Emergency Medicine Emory University School of Medicine Atlanta, Georgia

2. Teaching physician rules • Based on Medicare guidelines • Generally accepted and used by Medicaid and commercial payers • non-Medicare providers are not obligated to follow the rule • Fellows are considered residents • whether program is ACGME approved or not • some non-Medicare payers will exempt fellows from some or all of the rules

3. Teaching physician • Teaching physician must show personal involvement in the • evaluation • development of the plan of care • and treatment of the patient • must be clearly defined as the attending physician • Cannot just co-sign resident note • “agree with above and plan as written”

4. Teaching physician documentation • The teaching physician does not need to re-document the H&P • Must write a note personalized for that patient that shows that the teaching physician • has examined the patient • has reviewed the resident’s note • has reviewed the plan of care as written • notes any modifications to resident’s findings or plan of care • The combination of the resident and teaching physician note may be used to determine the level of documentation

5. Examples of ‘minimally acceptable documentation” • Patient seen at same time with resident • “I was present with 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.” • “I saw the patient with the resident and agree with the resident’s findings and plan.”

6. Examples of ‘minimally acceptable documentation” • Patient with or without the resident with the teaching physician independently performing the critical or key portion(s) of the service • “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.” • “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more consistent with bronchiolitis then asthma. Will defer steroids.”

7. Examples of unacceptable documentation • “Agree with above.” • “Discussed with resident. Agree.” • “Seen and agree.” • “Patient seen and evaluated.” • A legible countersignature or identity alone to the resident’s note

8. Teaching physician time based billing • May only bill for the time the teaching attending is actually present • may not count time resident alone was providing care • same rules apply to non-employed NP’s, PA’s without independent billing numbers

9. Teaching physician procedures • Only needs to be present for the ‘key’ or ‘critical’ portion of any billable procedure • for short procedures (<5 minutes) must be at the bedside for entire procedure • The determination as to what is the ‘key’ or ‘critical’ portion of the procedure is up to the teaching physician • The teaching physician must be immediately available for the entire procedure • must be in the unit where the procedure is performed

10. Medical students • Are not residents • even a ‘sub-intern’ may not be utilized as a resident for documentation and billing purposes • May only document ROS and PFSH in the medical record • May assist with procedures • teaching physician may not bill for any procedure exclusively performed by a medical student

11. Additional documentation • Your impressions • Differential diagnosis • Re-evaluations • Impression of ancillary test results • Information obtained from sources other than the primary historian • Medical care provided prior to patient’s arrival (EMS)