HCA Session III

1. HCASession III Teaching Physician Rules Time Based Coding; Counseling Q&A Prior Sessions

2. Teaching Physician Rules The purpose of this session is to provide you with the basic criteria for physician documentation of services provided in a teaching setting. Medicare Benefits: Part A (Hospital); Part B (Physician) In a teaching hospital, the hospital receives grant dollars (GME – Graduate Medical Education) for resident services. Residents cannot additionally bill for their individual services above and beyond this grant funding. However, the teaching physician can bill for patient care provided in collaboration with a resident to individual patients and bill Medicare Part B benefits under their Medicare provider ID Number.

3. You may bill for: Services personally furnished by a physician who is not a resident. A teaching physician who is physically present during the “critical; key portions” of the service that a resident performs his/her patient evaluation and/or procedure. Residents

4. Evaluation & Management Services E/M services billed by teaching physicians requires that they “personally” document the following: • That they personally performed the service or were physically present during the key/critical portions of the service when performed by the resident and • The participation of the teaching physician in the overall management of the patient. • The combined entries into the medical record by both the teaching physician and resident constitutes the documentation for the service and together must support the level of service billed. • Documentation by the resident alone of the presence/participation of the teaching physician is “not” sufficient to establish the presence of the teaching provider.

5. Key; Critical Portions When the teaching physician refers to a note obtained and documented by the resident (eg. HPI and physical examination) the teaching physician need not repeat the documentation of these components in detail. But, 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 such as a summary of: • 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 affirmation.

6. Key; Critical Portions For example, the teaching physician does not need to restate the : • Review of systems • Past, family and/or social information However, the teaching physician must document that he/she personally performed or was physically present during the critical or key portion(s) of the examination and was directly involved in the overall assessment/plan (eg. management) of the patient’s care.

7. Acceptable Documentation Admitting Note: “I performed the history & 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 for this patient”. Follow-Up: “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.” Or “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 further”.

8. Acceptable Documentation “I was present with the 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 and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.

9. 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. A legible countersignature or identity alone.

10. Medical Student Documentation by a student is limited to the: • Review of systems • Past, family and social information The teaching physician may “not” refer to the student’s physical examination or decision making documented in his/her own note. He/she must re-document the HPI and personally perform the exam.

11. Residents: Time Based Codes For procedure code selection to be determined on the “basis of time”, the teaching physician must be physical present” for the period of time for which the claim is being made. Payment will not be made for time spent by the resident in the absence of the teaching physician. Examples of non-billable resident services: • Individual medical psychotherapy • Critical Care • Hospital Discharge • E&M office visit codes when counseling predominants the discussion and the teaching physician is NOT present. .

12. Moonlighting “Moonlighting” refers to services performed outside the scope of an approved GME program. Medical, surgical, whether inpatient, outpatient or ER are billable under Part B (Physician) when the criteria below is met and the services are considered to have been furnished by The individuals in their capacity as a “physicians” vs. ‘resident”. Criteria: • The services require performance by a physician “in person” and contributes to the diagnosis or treatment of the patient’s condition. • The resident is fully licensed to practice medicine, osteopathy, podiatry etc by the state in which the services are performed. • The services can be separately identified from services that are required as part of an approved GME residency program.

13. Counseling – MD Billing General Rule: • If 50% or more of the total visit time is spent in discussion then select the cpt code that reflects the “total” time of the visit. Example: 15 min visit – 8 minutes was a discussion, remainder HPI, Exam. code 99213 (=15 minutes total time).

14. Office Visit Codes New Patients (NEW: not seen within 3 yrs by anyone in same specialty) 99201 = 10 minutes 99202 = 20 minutes 99203 = 30 minutes 99204 = 45 minutes 99205 = 60 minutes Established Patients 99211 = 5 minutes 99212 = 10 minutes 99213 = 15 minutes 99214 = 25 minutes 99215 = 40 minutes

15. Counseling - Depression Based on payor benefits available to primary care physicians whenever applicable code: • “Signs/symptoms” as primary reason for visit. You may list depression, anxiety as secondary. • Provide a summary of “key points” discussed to support “extent of time” being billed. • “Key Points” - emotional disturbances, maladaptive patterns of behavior, personal growth & development, patients response to supportive interactions w/clinician, patients response to cognitive discussions of reality w/clinician; communication w/family. • Non-Compliance