Involvement of Residents in Patient Care

1. Involvement of Residents in Patient Care Current Centers for Medicare and Medicaid Services (CMS) Guidance

2. GME Program • Residents, Fellows and Interns are paid through Graduate Medical Education (GME) • Teaching physicians’ responsibility to patient: • Services are rendered are medically necessary • Services are performed adequately • TP considered responsible for Medicare Beneficiary

3. Do the rules that apply to ‘Resident’ also apply to ‘Medical Student’? • Under CMS’ Rules for Billing Purposes a Teaching Physician may not utilize a medical student’s notes. • Documentation of a student’s note is limited to ROS and PFSH. • HPI, exam and/or MDM must be re-documented by the teaching physician. MCM 15016 Supervising Physician in Teaching Settings C.2. (E/M Service Documentation Provided by Students). November 2002

4. Nurse Practitioner • In a teaching setting, would a NP be considered as a resident? • Teaching physician rules do not apply to NPs. CMS has a separate policy for NP and physicians in the same group practice. Association of American Medical Colleges (AAMC) Frequently Asked Questions (Q17). December 2003

5. Responsibility • Does ‘primary medical responsibility’ mean the same as ‘assume management responsibility’? • CMS states this is a correct assumption • Is ‘reasonable and necessary’ equivalent to ‘ensured care provided was appropriate’? • The basic requirement for Medicare payment is that services are reasonable and necessary. AAMC Frequently Asked Questions (Q3). December 2003

6. SURGICAL PROCEDURE DOCUMENTATION GUIDANCE

7. Surgical Procedures Documentation • Who may document physical presence when TP is present for entire surgery? • The teaching physician or resident may document presence for entire procedure. MCM 15016 Supervising Physicians in Teaching Settings C.4.(Procedures). November 2002

8. Surgical Procedures Documentation • Who may document for presence during Critical/Key portions? • Teaching physician must document: • His/her own physical presence • What is considers to be the critical/key portions MCM 15016 Supervising Physicians in Teaching Settings C.4. (Procedures). November 2002

9. Teaching Surgeon Rules on Overlapping Surgical Procedures • Could the critical/key portions take place at the same time for both procedures? • No. When all of the key portions of the initial procedure have been completed, the TS may begin to become involved in the critical/key portions of a 2nd procedure. • When TS is not present during the non-critical/key portions and participating in a 2nd procedure: • Must arrange for another qualified surgeon to be immediately available to assist the resident should the need arise. MCM 15016 Supervising Physician in Teaching Settings C.4. (Procedures). November 2002.

10. Teaching Surgeon’s Responsibility • What is the criteria when the TS leaves the operating room after the critical portions? • In a single surgical procedure, he must be immediately available to furnish services during the entire procedure. AAMC Frequently Asked Questions (Q6). December 2003

11. Teaching Surgeon’s Responsibility • What is the criteria when the TS leaves the operating room after the critical portions? • In an overlap situation, • Must be present for critical/key portions of both surgeries. • Must arrange for another qualified surgeon to be immediately available to assist during non-critical/key portions. • RESIDENT DOES NOT QUALIFY AS ANOTHER PHYSICIAN FOR THIS PURPOSE. • Document qualified surgeon in the operative note or medical records AAMC Frequently Asked Questions (Q6). December 2003

12. Immediately Available • Would the requirement that a surgeon be “immediately available”, be met via a pager access and assured surgeon presence in OR within 5 minutes? • CMS’ states that: There is no specific definition of “immediately available”. The above example appears reasonable. AAMC Frequently Asked Questions (Q7). December 2003

13. Immediately Available • What documentation is required for a second surgeon to be immediately available in an overlap surgical situation? • While the guidelines contain no specific documentation requirements, the name of the second surgeon should be indicated either in the operative note or in the medical records. • Documenting on the template on the Operative Note is sufficient when completed. AAMC Frequently Asked Questions (Q10) December 2003

14. Medicare Teaching Physician RuleOverlapping Surgeries Scenario A: Case #1 Start Key Portion Stop Case #2 Start Key Portion Stop Both cases can be billed since neither overlaps with any portion of the other case.

15. Medicare Teaching Physician RuleOverlapping Surgeries Scenario B: Case #1 Start Key Portion Stop Case #2 Start Key Portion Stop Since the key portion of case #2 overlaps with case #1, case #1 cannot be billed unless a second surgeon was designated to meet the immediate availability requirement.

16. Medicare Teaching Physician RuleOverlapping Surgeries Scenario C: Case #1 Start Key Portion Stop Case #2 Start Key Portion Stop Since the key portion of case #2 overlaps with the key portion of case #1, case #2 cannot be billed. Since the teaching surgeon left the key portion of case #1 to become involved in the key portion of case #2, neither case can be billed.

17. Medicare Teaching Physician RuleOverlapping Surgeries Scenario D: Case #1 Start Key Portion Stop Case #2 Start Key Portion Stop Since case #2 is entirely overlapped by case #1, case #1 cannot be billed unless a second surgeon was designated to meet the immediate availability requirement.

18. Entire Procedure • Would the presence for the entire procedure include the opening and closing of the surgical site? • Yes. The Regulation states the TS is not required to be present for the opening and closing unless that portion is considered to be critical/key portion. • Minor procedures which usually take 5 minutes to complete, the TS is required to be present for the entire procedure. • Endoscopic procedures requirements include the teaching surgeon’s presence from insertion to withdraw of scope. In the scenario where the TS is presence for the entire procedure, the documentation may be by the teaching surgeon or the resident. MCM 15016 Supervising Physicians in Teaching Settings, C.4.(Procedures). November 2002

19. Pre- and Post- Operative Visits • Do the TP rules apply to pre operative visits? • Yes, a TP presence is required for the critical/key portions of a service. • Where pre-operative services are included in the global surgery period, and the TP determines the pre-operative services are not critical/key portions, his presence is not required. AAMC Frequently Asked Questions (Q25). December 2003

20. Documentation Supplements • Do pre-printed forms, questionnaires, medical record macros or checklists serve as adequate documentation? • No. A teaching physician/surgeon must note that he personally furnished a service. Such documentation must be dated and include the legible signature or identity of the teaching physician. However, pre-printed forms, questionnaires, medical records macros or check lists can be used to supplement written notes. AAMC Frequently Asked Questions (Q18). December 2003

21. Use of Macro • Are teaching physicians permitted to use Macros when dictating or typing their portion of the MR? • TP documentation must sufficiently describe the specific services furnished to the specific patient on a specific date. • If a TP’s only contribution to MR is limited to a macro, without any additional customized information, it is considered to be insufficient and could lead to a finding of fraud and abuse. CMS’ Physician Regulatory Issues Team (PRIT) Active Issue “Use of Macros in Teaching Documentation”

22. EVALUATION AND MANAGEMENT DOCUMENTATION GUIDANCE

23. Documentation Requirements Documentation requirements for all three scenarios include: • Physically presence (jointly) or perform key portions (independently) of the service • Participation in the care of the patient for all scenarios CMS’ Transmittal 1780 Supervising Physicians in Teaching Settings, Published November 2002

24. Key Portions Guidance • What portion of an E/M service is required under CMS’ Transmittal 1780, published in November 2002? • When a teaching physician determines that only the MDM is the key portion of the service, he must document his physical presence during the MDM. • He/she would not be required as prior to document each of the key components (history / exam / medical decision making). AAMC Frequently Asked Questions (Q9). December 2003

25. Determining Level of E/M Service • The teaching physician is responsible for ensuring that the appropriate level of an E/M service is assigned based on ‘medical necessity’ and supported by medical record documentation. • Resident may select the level—however, the teaching physician is responsible. AAMC Frequently Asked Questions (Q11). December 2003

26. Utilizing Resident’s Notes • Can more than one teaching physician utilize a single resident’s documentation? • NO!! • When more than one residents documents on the same day, is it necessary to clarify which resident the TP is referring? • TP must refer to resident by name or specialty (“if” specialty serves to identify the individual). AAMC Frequently Asked Questions (Q14 &15). December 2003

27. Time-Based Codes • Is a physician’s time spent teaching, included in time-based codes? • No… Only the time spent by the TP alone &/or with the resident is counted. • For time-based code descriptors with greater than 30 minutes, TP must document the actual time spent with the patient. Not required for descriptors of 30 minutes or less. AAMC Frequently Asked Questions (Q20) December 2003

28. Questions???Office of Corporate Compliance884-0632