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Teaching Physician Guidelines FAQ

This document reflects changes to the Medicare Carriers Manual by the Centers for Medicare and Medicaid Services (CMS) pursuant to Transmittal 1780 implemented on November 22, 2002. Significant changes were made to documentation required of teaching physicians for services performed by resident physicians, medical student contributions to documentation and performed services, and the definition of the critical or key portions of an E/M service. Included are updates pursuant to Transmittal 2247 effective June 1, 2011. Additional updates reflect changes made on advice of ACEP counsel.  

View the complete transmittals:

FAQ 1.  Do the Teaching Physician Guidelines apply to medical students, interns, residents, and fellows?

The Teaching Physician Guidelines apply to the care provided by interns, residents, and fellows ("residents"). Transmittal 1780 states that, "resident means 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. The term includes interns and fellows in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary. Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of 'resident'. Additionally, this status remains unaffected regardless of whether a hospital includes the physician in its full time equivalency count of residents. "Certain fellows may not meet the definition of a 'resident' in Transmittal 1780 and may be eligible to perform, document, and bill for services without additional oversight. A medical student is never considered to be an intern or resident and no service furnished by a medical student qualifies as a billable service under Medicare.

A medical student is never considered to be an intern or resident and no service furnished by a medical student qualifies as a billable service under Medicare.  FAQ 10 provides additional medical student performance and documentation guidance.  In addition, certain state regulations and other payer guidelines also have supervisory stipulations concerning medical students.  Refer to local payer and state regulations for guidance.

FAQ 2.  What is the basic requirement in order for the teaching physician to bill Medicare Part B for E/M service reimbursement?

In general, Medicare will pay for physician services furnished in a teaching setting under the physician fee schedule only if the services are furnished:

  • Personally by a teaching physician who is not a resident.
  • By a resident seeing a patient in the "physical presence" of a teaching physician who documents his or her presence during the performance of the critical or key portions of the service and discussion of the case with the resident.
  • Jointly by a teaching physician and a resident, seeing the patient at different times during a visit, provided the teaching physician independently performs the critical or key portions of the service and documents discussion of the case with the resident.
  • When a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day.

FAQ 3.  What are the basic documentation guidelines that the teaching physician must follow in order for his or her E/M services to be recognized by Medicare?

For purposes of payment, the teaching physician must at a minimum enter a personal notation documenting his or her performance of and/or physical presence during the key or critical portions of the service (as his or her performance of and/or physical presence during the key or critical portions of the service (as defined in FAQ 5). In addition, the teaching physician must document his or her participation in the management of the patient. Transmittal 1780 offers three common scenarios for teaching physicians providing E/M services. Transmittal 811 provides guidance on the use of macros and electronic medical records.

  1. The teaching physician performs all the requirements of an E/M service. The teaching physician must document as he or she would in a non-teaching setting or, where a resident has written notes, the teaching physician's note may reference the resident's note. The teaching physician must document that he or she performed, or personally supervised the resident's performance of the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient. For payment, the composite 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. In the absence of a note by a resident, the teaching physician must document as he or she would document an E/M service in a non-teaching setting. In this circumstance, the teaching physician personally performs all the requirements of an E/M service.
  1. 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 this service. In this case, the teaching physician must document that he or she was present during the performance of the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient. The teaching physician's note should reference the resident's note. For payment, the composite 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.
  1. The resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his or her service. The teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, discusses the case with the resident. In this instance, the teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The teaching physician's note should reference the resident's note. For payment, the composite 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.
  1. The teaching physician must document that he/she personally saw the patient and participated in the management of the patient. The teaching physician may reference the resident's note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient's condition has not changed, and the teaching physician agrees with the resident's note. The teaching physician's note must reflect changes in the patient's condition and clinical course that require that the resident's note be amended with further information to address the patient’s condition and course at the time the patient is seen personally by the teaching physician. The teaching physician’s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making regardless of whether the combination of the teaching physician’s and resident’s documentation satisfies criteria for a higher level of service. For payment, the composite 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.
  2. Documentation may be dictated, typed, hand-written, or computer-generated. Documentation must be dated and include a legible signature or identity. Pursuant to 42 CFR 415.172 (b), documentation must identify, at a minimum, the service furnished, the participation of the teaching physician in providing the service, and whether the teaching physician was physically present.

    In the context of an electronic medical record, the term 'macro' means a command in a computer or dictation application that automatically generates predetermined text that is not edited by the user.

    When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation if the teaching physician adds it personally in a secured (password protected) system. 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.  The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date.  It is insufficient documentation if both the resident and the teaching physician use macros only.

FAQ 4.  Has CMS provided examples of acceptable and unacceptable teaching physician documentation?

Examples of unacceptable teaching physician documentation include:

"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.

Such documentation is not acceptable, because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.

Examples of minimally acceptable documentation include:

"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 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 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."

On medical review, the combined entries into the medical record by the teaching physician and the resident constitute the documentation for the service and together must support the medical necessity of the service.

FAQ 5.  What is the definition of the critical or key portion(s) of a patient's evaluation as well as the key components of the Evaluation and Management services when billing for the services of a teaching physician?

As defined by CMS, critical or key portion means "that part (or parts) of a service that the teaching physician determines is (are) a critical or key portions."

For a given encounter, the selection of the appropriate level of Evaluation and Management (E/M) service should be determined according to the code definitions in the AMA CPT book and any applicable documentation guidelines.

Transmittal 1780 states that for the purposes of payment, E/M services billed by teaching physicians require that they personally document at least the following:

  1. That they performed the service or were physically present during the key or critical portions of the service when performed by the resident; and
  2. The participation of the teaching physician in the management of the patient.

FAQ 6.  What service must be provided and documented in order for the teaching physician to bill Medicare for surgical procedures?

For minor surgical procedures (lasting less than five minutes), the teaching physician must be physically present during the entire service. For major procedures (lasting more than five minutes), the teaching physician must be physically present during the "key portion(s)" of the service and must be immediately available to furnish service during the entire procedure. The teaching physician must document the extent of his/her participation.

FAQ 7.  Must the teaching physician be present in order to appropriately bill Medicare for timed services like critical care and moderate sedation?

Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching physician as critical care or other time-based services.  Time spent teaching may not be counted towards critical care time.  Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted when reporting a time based code.

FAQ 8.  What should a teaching physician document to report critical care when a resident is involved in the patients care?

A combination of the teaching physician’s documentation and the resident’s documentation may support critical care services.  Provided that all requires for critical care services are met, the teaching physician documentation may tie into the resident’s documentation.  The teaching physician may refer to the resident’s documentation for specific patient history, physical findings and medical assessment.  However, the teaching physician medical record documentation must provide substantive information, including: 

  1. time the teaching physician spent providing critical care, 
  2. that the patient was critically ill during the time the teaching physician saw the patient, 
  3. what made the patient critically ill; and 
  4. the nature of the treatment and management provided by the teaching physician.  The medical review criteria are the same for the teaching physician as well as for all physicians.

The medical review criteria are the same for the teaching physician as well as for all physicians.

 CMS Manual System Pub 100-04 Medicare Claims - Transmittal 1548 

FAQ 9.  What are the specific requirements for Medicare billing when a resident has been involved in the care of a patient?

When the CMS 1500 form is filled out certain modifiers are required by Medicare to provide information in respect of teaching physician services that do not affect payment levels. In the case of teaching physicians, two modifiers are available and are found in the HCPCS Level II National Modifier list. These modifiers are reported in the modifier column of the CMS1500 form next to the service to which they are being applied. These modifiers must be added if the service of a resident is being counted for credit towards the documentation requirements of a teaching physician. These modifiers must be added to all such services or procedure codes that had resident participation.

GC
This service has been performed in part by a resident under the direction of a teaching physician. (The usual circumstance in an ED with residents working under the guidance and supervision of teaching physicians).

GE
This service has been performed by a resident without the presence of a teaching physician under the primary care exception.

FAQ 10.  What are the specific performance and documentation requirements for Medicare billing when a medical student has been involved in the care of a patient?

An independent evaluation or procedure provided by a medical student cannot be used in determining the appropriate Medicare services. Any contribution and participation of a medical student to a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a resident and/or teaching physician. Students may also document services in the medical record; however, the teaching physician must verify and document the HPI, examination, and medical decision making of the student. An ROS, PFSH performed and documented by a medical student must be confirmed with the patient and the teaching physician must document his/her confirmation of the ROS, PFSH.

Teaching physicians can involve students in services they personally perform. CMS allows the teaching physician who personally performs an evaluation or procedure to personally supervise medical student involvement. If a medical student is involved in a procedure performed by a resident, the teaching physician may supervise and bill for that procedure providing the documentation requirements described in FAQ 6 are met. In addition, certain state regulations and other payer guidelines also have supervisory stipulations concerning medical students. Refer to local payer and state regulations for guidance.

FAQ 11.  What are the specific requirements for Medicare billing when a resident has been involved in interpretation of diagnostic radiology and other diagnostic test?

Medicare pays for the interpretation of diagnostic radiology and other diagnostic test if the interpretation is performed by or reviewed with a teaching physician. If the teaching physician's signature is the only signature on the interpretation, Medicare assumes that he/she is indicating that he/she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the resident's interpretation and either agrees with it or edits the findings. Medicare does not pay for an interpretation if the teaching physician only countersigns the resident's interpretation.

Last Updated 04/2014

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