CMS policy update: E/M services performed under the teaching physician rules
Did you see that CMS updated its teaching physician rules? In the 2019 Final Rule, they told us they were going to do it, and here are the details. CMS released a transmittal on April 26. I’ve updated this article to reflect the changes. Frankly, I’m surprised and still digesting the news.
The teaching physician (TP) rules describe a payment method by which Medicare pays an attending physician or teaching physician for services performed jointly with an intern, resident, or fellow, in an approved graduate medical education program (GME). The teaching physician’s presence and participation is required. Add modifier GC to all services provided under the teaching physician rules.
Definition of Modifier GC:
Service has been performed in part by a Resident under the direction of a teaching physician.
Teaching physician services are billed using the teaching physician’s provider number.
- The documentation must be dated, and contain a legible signature or electronic signature
- It helps to indicate specialty in the heading of your note, such as cardiology fellow note, or family medicine visit.
- Document services personally performed, either dictated and transcribed, typed, handwritten or computer-generated
Evaluation and Management (E/M) Service provided jointly with a resident
What must the attending physician do and document?
- 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.”
The transmittal has an effective date of January 1, 2019, a release date of April 26, 2019 and an implementation date of July 29, 2019. The transmittal, and the MedLearn Matters article when it is published, describe the change that was indicated in the 2019 Physician Fee Schedule Final Rule, and CMS administrator Seema Verma’s letter to clinicians on reducing burden.
Neither the Final Rule nor her letter gave any specifics. Ms Verma’s letter said effective January 1, 2019,
“Remove potentially duplicative requirements for certain notations in medical records that may have previously been documented by residents or other members of the medical team.”
I’ve posted that letter for you, here.
The Final Rule said,
“We proposed to revise our regulations to eliminate potentially duplicative requirements for notations that may have previously been included in the medical records by residents or other members of the medical team. These modifications are intended to align and simplify teaching physician E/M service documentation requirements. We believed these changes would reduce burden and duplication of effort for teaching physicians.” And “We proposed to add new paragraph (a)(6) to §415.174 to provide that the medical record must document the extent of the teaching physician’s participation in the review and direction of services furnished to each beneficiary, and that the extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by a physician, resident, or nurse.” 
The two and a half pages from the rule related to this are posted here.
The CMS manual system will be updated with the wording from Transmittal 4283. You can read the transmittal for yourself.
CMS’s Teaching Physician fact sheet allows the use of macros.
“The teaching physician may use a macro as the required personal documentation if he or she personally adds it in a secured or 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. If both the resident and the teaching physician use only macros, this is considered insufficient documentation.”
In 2018, CMS updated its teaching physician policy regarding documentation of medical student services, as well. Prior to April, 2018, an attending could only use the ROS and PFSH in selecting the level of service for an E/M code. The wording in the manual changed to indicate that while the attending was responsible to verify all student documentation, there was no prohibition on using that documentation, and the attending would not have to re-document.
The manual says,
“Students may document services in the medical record. However, 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”.
It doesn’t say the attending doesn’t have to do the work, only that if the student has documented a portion of the E/M note, the attending doesn’t have to re-document it.
Nurse practitioner students and physician assistant students
Changes for 2020
Documentation performed by medical students, advance practice nursing students and physician assistant students:
Per CMS: “Therefore, we propose to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the PFS.”
- Now, physician assistant and nurse practitioner students are treated the same way as medical students for documentation purposes.
- Any physician or NPP who bills a service can “review and verify” rather than re-document.
- Includes “information included in the medical record by physicians, residents, nurses, students or other members of the medical team.”
E/M services based on time
This policy did not change in 2019. When a procedure code is used that is selected based on time, count only the time the attending was physically present with the patient in selecting the code. Do not add together the time of the resident and the attending to select the code. Examples of this are:
- E/M services in which counseling or coordination of care dominates the visit, and time is used to select the E/M service
- Individual psychotherapy
- Critical care codes 99291—99292
- Hospital discharge day management 99238—99239
- Non-face-to-face prolonged services codes 99358—99359
- Care plan oversight HCPCS codes G0181—G0182
Critical care billing
The teaching physician must be present for the entire period of time for which the claim for payment is made. Resident time does not count towards the critical care time.
- The teaching physician must personally see the patient and spend more than 30 minutes of critical care time.
- The attending must perform a critical care service and must participate in the management of the care.
- The teaching physician must document time spent in critical care in the medical record.
- The resident’s note may serve to add detail to the nature of the patient’s illness, the treatment provided and the critical condition of the patient.
- Count only the attending’s time for billing.
 CMS Transmittal 4283, April 26, 2019, CR 11171
 HHS, CMS “Dear Clinician” letter
 CMS 2019 Physician Fee Schedule Final Rule, p. 636
 Medicare Claims Processing Manual, 100-04, Chapter 12, Section 100.1.1 B
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