When hospitalists work in academic centers, medical and surgical services are furnished, in part, by a resident within the scope of the hospitalists’ training program. A resident is “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.”1 Resident services are covered by Centers for Medicare & Medicaid Services (CMS) and paid by the Fiscal Intermediary through direct GME and Indirect Medical Education (IME) payments. These services are not billed or paid using the Medicare Physician Fee Schedule. The teaching physician is responsible for supervising the resident’s health-care delivery but is not paid for the resident’s work. The teaching physician is paid for their personal and medically necessary service in providing patient care. The teaching physician has the option to perform the entire service, or perform the self-determined critical or key portion(s) of the service.
Teaching physicians independently see the patient and perform all required elements to support the visit level (e.g. 99233: subsequent hospital care, per day, which requires at least two of the following three key components: a detailed interval history, a detailed examination, or high-complexity medical decision-making).2 The teaching physician writes a note independent of a resident encounter with the patient or documentation. The teaching physician note “stands alone” and does not rely on the resident’s documentation. If the resident saw the patient and documented the encounter, the teaching physician might choose to “link to” the resident note in lieu of personally documenting the entire service. The linking statement must demonstrate teaching physician involvement in the patient encounter and participation in patient management. Use of CMS-approved statements is best to meet these requirements. Statement examples include:3
- “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.”
- “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
- “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.”
Each of these statements meets the minimum requirements for billing. However, teaching physicians should offer more information in support of other clinical, quality, and regulatory initiatives and mandates, better exemplified in the last example. The reported visit level will be supported by the combined documentation (teaching physician and resident).
The teaching physician submits a claim in their name and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99223-GC). This alerts the Medicare contractor that services were provided under teaching physician rules. Requests for documentation should include a response with medical record entries from the teaching physician and resident.
“Supervised” service: The resident and teaching physician can round together; they can see the patient at the same time. The teaching physician observes the resident’s performance during the patient encounter, or personally performs self-determined elements of patient care. The resident documents their patient care. The attending must still note their presence in the medical record, performance of the critical or key portions of the service, and involvement in patient management. CMS-accepted statements include:3
- “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 the patient with the resident and agree with the resident’s findings and plan.”
Although these statements demonstrate acceptable billing language, they lack patient-specific details that support the teaching physician’s personal contribution to patient care and the quality of their expertise. The teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99232-GC).
“Shared” service: The resident sees the patient unaccompanied and documents the corresponding care provided. The teaching physician sees the patient at a different time but performs only the critical or key portions of the service. The case is subsequently discussed with the resident. The teaching physician must document their presence and performance of the critical or key portions of the service, along with any patient management. Using CMS-quoted statements ensures regulatory compliance:3
- “I saw and evaluated the patient. I reviewed the resident’s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
- “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”
- “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”
- “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.”
Once again, the teaching physician selects the visit level that represents the combined documentation and, if it is a Medicare claim, appends modifier GC to the selected visit level (e.g. 99233-GC).
When seeing patients independent of one another, the timing of the teaching physician and resident encounters does not impact billing. However, the time that the resident encounter is documented in the medical record can significantly impact the payment when reviewed by external auditors. When the resident note is dated and timed later than the teaching physician’s entry, the teaching physician cannot consider the resident’s note for visit-level selection. The teaching physician should not “link to” a resident note that is viewed as “not having been written” prior to the teaching physician note. This would not fulfill the requirements represented in the CMS-approved language “I reviewed the resident’s note and agree.”
Electronic health record (EHR) systems sometimes hinder compliance. If the resident completes the note but does not “finalize” or “close” the encounter until after the teaching physician documents their own note, it can falsely appear that the resident note did not exist at the time the teaching physician created their entry. Because an auditor can only view the finalized entries, the timing of each entry might be erroneously represented. Proper training and closing of encounters can diminish these issues.
Additionally, scribing the attestation is not permitted. Residents cannot document the teaching physician attestation on behalf of the physician under any circumstance. CMS rules require the teaching physician to document their presence, participation, and management of the patient. In an EHR, the teaching physician must document this entry under his/her own log-in and password, which is not to be shared with anyone.
CMS defines student as “an individual who participates in an accredited educational program [e.g. a medical school] that is not an approved GME program.”1 A student is not regarded as a “physician in training,” and the service is not eligible for reimbursement consideration under the teaching physician rules.
Per CMS guidelines, students can document services in the medical record, but the teaching physician may only refer to the student’s systems review and past/family/social history entries. The teaching physician must verify and redocument the history of present illness. A student’s physical exam findings or medical decision-making are not suitable for tethering, and the teaching physician must personally perform and redocument the physical exam and medical decision-making. The visit level reflects only the teaching physician’s personally performed and documented service.
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
- Centers for Medicare and Medicaid Services. Guidelines for Teaching Physicians, Interns, Residents. CMS website. Available at: http://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf. Accessed Jan. 8, 2013.
- Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2013.
- Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 30.2. CMS website. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan. 8, 2013.