CMS policy update: E/M services performed under the teaching physician rules
Download this teaching physician rules quick reference sheet for a summary of the rules.
The CMS rules got a major update with the April 26, 2019 Transmittal 4823. A transmittal is a communication from CMS to the Medicare Administrative Contractors. It is followed by an update to the CMS Claims Processing Manual and the release of a MedLearns Matter article, explaining the change.
The new rules allow the attending, the resident or the nurse to document the attending’s participation in the care of the patient when performing an E/M service. CMS said they were going to do this in the 2019 Physician Fee Schedule Final Rule, released in November of 2018, but the transmittal wasn’t released until April 26, although there is an effective date of January 1, 2019 and an implementation date of July 1, 2019. The transmittal does not include any of the examples of linking statement that were in the manual for so many years. It is brief—here is the section on E/M.
100.1.1 – Evaluation and Management (E/M) Services
(Rev. 4283, Issued: 04- 26-19, Effective: 01-01-19, 07-29-19)
A. General Documentation Requirements
Evaluation and Management (E/M) Services — For a given encounter, the selection of the appropriate level of E/M service should be determined according to the code definitions in the American Medical Association’s Current Procedural Terminology (CPT®) book and any applicable documentation guidelines.
For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:
- That the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and
- The participation of the teaching physician in the management of the patient.
The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.
However, the May 2023 “Teaching Physicians, Interns and Residents Guide” says on page 8:
Your joint medical record entries (you and the resident) make up the documented service and it must cover medical necessity. Residents may not justify medical necessity by documenting the teaching physician’s presence during the services.
How might these new rules be implemented in teaching settings? If there are team rounds that include residents, fellows and the attending, and the attending is physically present in the room for the history and exam, and participates in the treatment plan, the resident can note that.
If the attending sees the patient at another time, the attending would still need to perform the service. In that case, the documentation of the attending’s participation in the care could be documented by the attending, or by the resident or nurse.
- The teaching physician must either perform the service or be present when the resident performs the key or critical components,
- The teaching physician must participate in the care,
- The record should demonstrate this, and the documentation of it may be provided by the attending, resident or nurse.
- If the attending sees the patient at a different visit than the resident, it is likely that the attending will personally document his or her participation in the care.
- Some groups have opted to continue to use the attestation statements that were in place before these rules changed.
Supervision of E/M during the PHE
In other words, the teaching physician must provide supervision either with physical presence or be present through interactive telecommunications technology during the key portion of the service. Specifically, we believe that when use of such real-time, audio and video telecommunications technology allows for the teaching physician to interact with the resident through virtual means, their ability to furnish assistance and direction could be met without requiring the teaching physician’s physical presence for the key portion of the service. March 30, 2020 rule CMS-1744-IFC
- Direct supervision by interactive tele-communications technology
- TP must be either physically present or be present with resident through interactive technology during the key portions of the service
 CMS Transmittal 4283, April 26, 2019, CR 11171
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