Transcript HCA - Harvard University

HCA
Session III
Teaching Physician Rules
Time Based Coding; Counseling
Q&A Prior Sessions
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.
Residents
You may bill for:
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Services personally furnished by a physician who is not a resident.
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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.
Evaluation & Management Services
E/M services billed by teaching physicians requires that they “personally” document the
following:
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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.
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:
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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.
Key; Critical Portions
For example, the teaching physician does not need to restate the :
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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.
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”.
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.
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.
Medical Student
Documentation by a student is limited to the:
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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.
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:
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Individual medical psychotherapy
Critical Care
Hospital Discharge
E&M office visit codes when counseling predominants the discussion and the teaching physician is
NOT present.
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:
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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.
Counseling – MD Billing
General Rule:
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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).
Office Visit Codes
New Patients
(NEW: not seen within 3 yrs by anyone in same specialty)
99201 =
99202 =
99203 =
99204 =
99205 =
10
20
30
45
60
minutes
minutes
minutes
minutes
minutes
Established Patients
99211 = 5 minutes
99212 = 10 minutes
99213 = 15 minutes
99214 = 25 minutes
99215 = 40 minutes
Counseling - Depression
Based on payor benefits available to primary care physicians whenever applicable
code:
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“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