Teaching Physician Payment
Regulations Under the Medicare Part B Program; Billing for
the Services of Resident and Fellows in Their Own Name
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Related Resources
AAMC Documents
- Feb.
9, 1998 letter from Dr. McCann
- Summary of Final
Rule (PDF - 1 page, 13 KB)
-
Final Carrier Manual Instructions (PDF - 3
pages, 95 KB)
- HCFA
Clarification on Primary Care Exception, Oct. 15,
1998 (PDF, 3 pages - 650 KB)
- November
4, 1998 Memo on Clarification of Medical Student Documentation(PDF,
1 page - 59 KB)
- Conditions
for Payment of Medically Directed Anesthesia Services
(PDF, 1 page - 197 KB)
- Medicare
Documentation Instructions and Sample Templates
(PDF - 11 pages, 1.11 MB)
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Background
The final rule for teaching physicians has been in effect
since July 1, 1996. Periodic clarifications of the rule have
been issued by HCFA in addition to the final Carrier Manual
Instructions.
The Medicare program's final rule for teaching physicians
replaced Intermediary Letter 372 Guidelines (IL-372) that
were in effect for nearly 30 years. IL-372 specified the requirements
for billing by teaching physicians when these services involved
residents. The criteria for billing expressed in IL-372 were
ambiguous and not well communicated by the Health Care Financing
Administration (HCFA) and its local carriers relative to the
requirements for the physical presence of the supervising
teaching physician for visit and consultation services. However,
the guidelines did specify the need for the presence of the
teaching physician during major and complex surgical procedures.
The AAMC considers the 1996 final rule to be new policy with
a new set of requirements that are substantially different
from the payment policy for teaching physicians expressed
in IL-372 Guidelines. (A complete summary of the final rule
is contained in a presidential memo #95-68, issued December
16, 1995 and additional clarifications issued on October 25,
1996, February 3, 1997, and February 9, 1998.)
The general rule, effective July 1, 1996, is as follows:
If a resident (or fellow) participates in a service
furnished in a teaching setting, a Part B payment will be
allowed only if the teaching physician is present to perform
or observe the resident perform, the "key" portion
of any service or procedure for which payment is sought. Each
individual physician may determine the "key" portion
of any service or procedure furnished. The "key"
portion for a visit or consultation service is defined in
CPT as including the activities of history, physical exam
and medical decision-making. The "key" portion for
a surgical or diagnostic procedure is self-defined by the
physician.
The rule provides for an exception to the general physical
presence requirement for low level visit services provided
in certain primary care outpatient centers by residents being
trained in the specialties of general internal medicine, family
practice, gerontology, OBGYN and pediatrics.
Documentation Requirements
The teaching physician has special documentation instructions
under the final rule. The teaching physician may substantiate
any service billed to the Medicare program by writing or dictating
a summary note of the services performed personally or directly
observed. The teaching physician's note may be a summary note
that confirms or revises the history of present illness, the
exam, and the medical decision making activities, combined
with the more detailed note of the resident. (See AAMC templates
on how to structure an appropriate note for EM services.)
For other services, such as a single surgical procedure and
diagnostic tests, a simple attestation of physical presence
of the teaching physician during the key portion of the procedure
or test is all that is required. For overlapping, concurrent
surgical procedures performed or observed by the teaching
physician, however, he/she must provide a patient-specific
personal note of the procedures billed.
Billing for the Services of Residents and Clinical Fellows
"In Their Own Name"
The rule also addresses the circumstances for when it is
appropriate to bill for the services of residents and clinical
fellows "in their own name". A resident or fellow
may bill for services they perform in their own name in only
two situations: 1) when under in a moonlighting situation;
and 2) if providing service in an unapproved training program,
that is a program not approved by the ACGME or the ABMS.
(For complete details on these issues, link to the final
Carrier Manual Instructions, issued May 1997 and the AAMC
Memo #96-12 on the Billing for the Services of Clinical Fellows,
issued March 10, 1996. For the complete text of the HCFA final
rule for teaching physicians, see the Federal Register, volume
60, December 8, 1995 in text format and PDF format).
Administration Action
Various clarifications have been issued by HCFA since the
final rule was published.
AAMC Action
AAMC staff have worked continuously to clarify the provisions
of the final rule. These have been communicated to the membership
via the internet and presidential memos.
Contacts
Denise Dodero, Associate Vice President
AAMC Health Care Affairs
ddodero@aamc.org
(202) 828-0493
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