Physicians at Teaching Hospitals

Objective

To ensure that all services in which residents are involved are correctly billed in accordance with applicable rules and regulations regarding physician services in teaching settings. For purposes of this policy, a ‘resident’ includes a resident, intern, or fellow participating 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. A “teaching physician” is a physician, other than another resident, who involves residents in the care of his or her patients.

Policy

Because we are an academic medical center and train and educate medical residents, we are governed by the Federal regulations concerning physician services in teaching settings (42 C.P.R. 415, Subpart D). Those regulations provide that, as a general rule, if a resident participates in a service furnished in a teaching setting, a teaching physician may receive payment for those services under the Medicare Physician Fee Schedule only if the teaching physician was present during the key portions of the service or procedure for which payment is sought. There are some exceptions to the general rule:

  • In the case of surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire procedure. If circumstances present a teaching physician from being immediately available during a surgical procedure, then he/she must arrange for another qualified surgeon to be immediately available to assist with the procedure, if needed.
  • Minor procedures – For procedures that take only a few minutes (5 minutes or less) to complete, e.g., simple suture, and involve relatively little decision making once the need for the operation is determined, the teaching surgeon must be present for the entire procedure in order to bill for the procedure.
  • In the case of E/M services, the teaching physician must be present during the portion of the service that determines the level of service billed. However, in the case of E/M services furnished in hospital outpatient departments and certain other ambulatory settings, different requirements apply.
  • Additional exceptions to the general rule apply for renal dialysis services, anesthesia services and psychiatric services.

In the case of E/M services, the teaching physician must personally document his or her participation in the service in the medical records. The teaching physician may not bill for his/her services based upon a countersignature alone, but must instead provide his or her own written documentation. In order for a teaching physician to bill for his/her E/M services, the teaching physician must personally document at least the following: (1) that he or she performed the service or was 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. Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician. On medical review, the combined entries in the medical record by the teaching physician and resident constitute the documentation for the service and together must support the medical necessity of the service.

 

For CPT-4 codes determined on the basis of time, such as critical care codes, the teaching physician must be present for the entire period of time for which the claim is submitted. 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’s 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: 

(1) the 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.

 

 

Office for Billing Compliance
Policy#: OFBC 10013
Original Date of Issue: 1996
Revised: 3/22/2023
Reviewed: 3/1/2024