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 have been made to documentation required of teaching physicians for services performed by resident physicians, medical student contributions to documentation, and the definition of the critical or key portions of an E/M service. Included below are references for several transmittal updates.
View the complete transmittals:
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. However, as of 5-31-18 teaching physicians can now review and verify medical student documentation. In addition, as of 1-1-2020 teaching physicians and Advanced Practice Providers (APP’s) can now review and verify Physician Assistant (PA) and Nurse Practitioner (NP) student documentation as well. See FAQ’s 12-16 for additional student performance and documentation guidance. The reader is reminded that certain states may have regulations and other payer guidelines concerning students.
Do the Teaching Physician guidelines apply to residents or fellows “moonlighting” at another hospital?
No. If a resident or fellow is “moonlighting” at a hospital that is not part of their graduate medical education, and they are working as a fully licensed physician in the state, then they are in essence working as an attending physician. Providers are encouraged to check local payer and state regulations.
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:
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 sign and date documentation prepared by a resident, nurse or student. The presence and participation of the teaching physician in the management of the patient must be documented.
“…the clinician may review and verify (sign/date) notes in a patient’s medical record made by other physicians, residents, nurses, students, or other members of the medical team, including notes documenting the practitioner’s presence and participation in the services, rather than fully re-documenting the information.”
Please note that there has NOT been any change to WHAT must be documented in the medical record. The recent CMS changes only address WHO can document the services provided in the medical record.
“We also noted that, while the proposed change addresses who may document services in the medical record, subject to review and verification by the furnishing and billing clinician, it would not modify the scope of, or standards for, the documentation that is needed in the medical record to demonstrate medical necessity of services, or otherwise for purposes of appropriate medical recordkeeping.”
In addition, CMS has now made it clear that the new documentation policy applies broadly to all services of physicians, PAs and NPs regardless of the type of service furnished (e.g., E/M, procedure, or diagnostic test).
“… our proposed medical record documentation policy would apply broadly to all services of physicians, PAs and APRNs, regardless of the type of service (E/M, procedure, diagnostic test) or the setting in which the service is furnished.”
Reference: 2019 CMS Final Physician Fee Schedule
Taken all together, although no change has been made to the documentation requirements for the Emergency Medicine E/M codes 99281-99285, CMS has certainly provided some relief as to the extent of the teaching physician attestation required. In transmittal 4283, CMS also eliminated all of the previous examples of “acceptable” and “unacceptable” documentation. ACEP offers the following sample attestation when supervising a resident for your consideration:
I, Dr. X, personally saw the patient, performed critical or key portions of the service, and discussed the care with the resident.
For payment, the composite of the teaching physician's entry and the resident's entry together must support the medical necessity of the services provided and the level of the service billed by the teaching physician. The above attestation would cover E/M services in addition to any procedures or diagnostic tests.
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. When using an electronic medical record, it is acceptable for the teaching physician to use a macro for documentation if the teaching physician adds it personally in a secured (password protected) system. 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 patient on the specific date of service. It is insufficient documentation if both the resident and the teaching physician only use generic macros.
Has CMS provided examples of acceptable and unacceptable teaching physician documentation?
In transmittal 4283 dated 4-26-19, CMS eliminated all of the examples previously provided of acceptable and unacceptable documentation. Although CMS has expanded who can document the teaching physician’s presence and participation, the teaching physician must still perform or be present for at least the key or critical elements of the service. Until further guidance is given, ACEP encourages teaching physicians to make sure the medical record or their attestation incorporate these elements.
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.
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.
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.
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 teaching physician personally caring for the patient or together with a resident may be counted when reporting a time-based code.
What should a teaching physician document to report critical care when a resident is involved in a patient's care?
A combination of the teaching physician’s documentation and the resident’s documentation may support critical care services. Provided that all requirements 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's medical record documentation must provide substantive information, including:
What are the specific modifiers to use 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.
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).
This service has been performed by a resident without the presence of a teaching physician under the primary care exception.
What are the specific requirements for Medicare billing when a resident has been involved in interpretation of diagnostic radiology and other diagnostic testing?
Medicare pays for the interpretation of diagnostic radiology and other diagnostic testing 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.
What are the Medicare performance and documentation requirements when a medical student is involved in the care of a patient?
As a result of CMS transmittal 3971 issued on 2/2/18, a medical student’s note became more meaningful. Per CMS’s new guidelines, a teaching physician can now use a medical student’s note to document and bill for a patient’s visit.
As before, any contribution and participation of a medical student to a billable service (other than the review of systems and/or past family/social history) must be performed in the physical presence of a resident or teaching physician. CMS has previously defined “physically present” to mean the teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.
In order to use the medical student’s note for billing, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.
What recommendations would you give teaching physicians when using medical student documentation?
The teaching physician should document that he/she personally saw the patient and participated in the management of the patient. In order to use medical student documentation in the medical record, the teaching physician should enter a personal notation verifying the history, physical examination, and medical decision making.
For clarity, it may be helpful for teaching physicians to include an attestation such as:
I, Dr. X, personally verified the history, examined the patient with the student and performed the medical decision making. I agree with the documentation & plan of care.
What guidance would you give a medical student when helping to document a patient encounter for a teaching physician?
A medical student is not licensed to provide any care independently, but they may assist a teaching physician by documenting the history, physical exam, and medical decision making including the plan of care for a patient. All patients seen by a medical student must be seen and have their care supervised by a physician.
For clarity, it may be helpful for a medical student to include an attestation that they helped prepare the note for the teaching physician such as: “I, Linda Smith, MS IV, helped prepare the medical record for my supervising physician, Dr. X”.
What are the requirements for documenting a procedure when a medical student is involved?
A medical student is not licensed to perform procedures independently, but they may assist a teaching physician who performs a procedure as long as they are personally supervised. Teaching physicians should verify all medical student documentation, including any procedure notes. If a medical student is involved in a procedure performed by a resident, the teaching physician may report the procedure providing the teaching physician supervisory requirements described in FAQ 6 are met.
How does the 2019 CMS Physician Final Rule apply to Nurse Practitioner (NP) and Physician Assistant (PA) Students?
The 2019 Physician Final Rule expands the definition of student to include PA & NP students. Everything stated above concerning medical students in FAQ’s 12-15 now applies to PA & NP students as of 1/1/2020. Note is made that PA’s and NP’s can also supervise PA & NP students and use their documentation in a similar manner.
Updated February 2022
The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only. The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.
The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.
For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or email@example.com.