Revisions to Medicare Carrier
Manual Instructions on Supervising Physicians in Teaching
Settings
On November 22, 2002, the Centers for Medicare and Medicaid
Services (CMS) published changes to the Carrier Manual Instructions
(CMI), Section 15016, Supervising Physicians in Teaching Settings.
The revisions are located at http://www.cms.hhs.gov/manuals/transmittals/
the CR # is 2290. The revisions were effective on the date
they were issued.
While the teaching physician regulation that was effective
on July 1, 1996 remains unchanged, the revised CMI makes important
positive changes in the documentation requirements by reducing
the amount of personal documentation that the teaching physician
must provide when a resident also writes a note. The revised
language makes it clear that for E/M services, teaching physicians
need not repeat documentation already provided by a resident.
Further, the revisions clarify other issues, including the
use of documentation by students, and updates regulatory references.
The instructions should be carefully reviewed by each institution.
Background
Of special interest to AAMC members have been the federal
government's payment rules when a teaching physician provides
care to a Medicare beneficiary while simultaneously teaching
a resident. The Health Care Financing Administration (HCFA,
now CMS) first established guidelines for billing practices
of teaching physicians in 1967. The requirements were again
addressed in 1969 when HCFA issued Intermediary Letter 372
(IL-372), which delineated the criteria to be met by teaching
physicians before submitting a bill for payment of services.
Questions continued to be raised about when and to what extent
the physical presence of the teaching physician was required
for billing Medicare. Adding to the confusion were the inconsistent
interpretation and enforcement of the rules by local Medicare
carriers.
In December 1995, HCFA published new regulations, effective
July 1996, that detailed when a teaching physician could appropriately
bill Medicare for patient care services in which a resident
also is involved. The regulations were intended to reduce
substantially the ambiguities engendered by the previous HCFA
guidelines. They require, with one narrow exception, that
the teaching physician be present to perform or observe the
"key portion" of any service or procedure for which
payment is sought and provide further guidance on the documentation
required in the medical record to substantiate that such services
were performed. Soon after the rules were issued, CMS also
published a revised CMI to provide additional information
needed to implement the new rules. Despite the increased clarity
under the new rules and CMI, some of the documentation requirements
were considered to be overly burdensome and impeded both the
delivery of patient care services and the teaching process.
CMS has been examining the regulatory burden on physicians
and attempting to provide relief when feasible. Over the past
year, the Agency has worked with AAMC through the Group on
Faculty Practice Steering Committee to identify burdensome
aspects of the supervising physician requirements that could
be addressed through revisions to the Carrier Manual Instructions
rather than through changes in the regulation. The revised
CMI should significantly reduce the documentation burden on
teaching physicians for E/M services when a resident also
is involved in the care of a patient. It is important to note
that with very limited exceptions, a teaching physician still
must write a personal note and, unless the service is provided
under the Primary Care Exception, must be present for the
"key portion" of the service.
Summary of Revisions
Definitions
Among the definitions that CMS has added to the Carrier Manual
Instructions are:
Resident: "The term includes interns and fellows in
GME programs recognized as approved for purposes of direct
GME payments made by the fiscal intermediary. Receiving a
staff or faculty appointment or participating in a fellowship
does not by itself alter the status of "resident".
Additionally, this status remains unaffected regardless of
whether a hospital includes the physician in its full time
equivalency count of residents."
Documentation: "Notes recorded in the patient's medical
record by a resident and/or teaching physician or others as
outlined in specific situations regarding the service furnished.
Documentation may be dictated and typed, hand-written or computer-generated
and typed or handwritten. Documentation must be dated and
include a legible signature or identity. Pursuant to 42 CFR
415.172(b), documentation must identify at a minimum the service
furnished, the participation of the teaching physician in
providing the service and whether the teaching physician was
physically present."
Physically present: The teaching physician is located in
the same room (or partitioned or curtained area, if the room
is subdivided to accommodate multiple patients) as the patient
and/or performs a face-to-face service.
General Documentation Instructions and Common Scenarios
CMS has clarified that for purposes of payment, Evaluation
and Management (E/M) services billed by teaching physicians
require that they personally document at least the following:
a. That they performed the service or were physically present
during the key or critical portions of the service when performed
by the resident; and
b. The participation of the teaching physician in the management
of the patient.
Following are three common scenarios for teaching physicians
providing E/M services:
Scenario 1 -
The teaching physician personally performs all the required
elements of an E/M service without a resident. In this scenario
the resident may or may not have performed the E/M service
independently.
· In the absence of a note by a resident, the teaching
physician must document as he or she would document an E/M
service in a non-teaching setting.
· Where a resident has written notes, the teaching
physician's note may reference the resident's note. The teaching
physician must document that he or she performed the critical
or key portion(s) of the service and that he or she was directly
involved in the management of the patient. For payment, the
composite of the teaching physician's entry and the resident's
entry together must support the medical necessity of the billed
service and the level of the service billed by the teaching
physician.
Scenario 2 -
The resident performs the elements required for an E/M service
in the presence of, or jointly with, the teaching physician
and the resident documents the service. In this case, the
teaching physician must document that he or she was present
during the performance of the critical or key portion(s) of
the service and that he or she was directly involved in the
management of the patient. The teaching physician's note should
reference the resident's note. For payment, the composite
of the teaching physician's entry and the resident's entry
together must support the medical necessity and the level
of the service billed by the teaching physician.
Scenario 3 -
The resident performs some or all of the required elements
of the service in the absence of the teaching physician and
documents his/her service. The teaching physician independently
performs the critical or key portion(s) of the service with
or without the resident present and, as appropriate, discusses
the case with the resident. In this instance, the teaching
physician must document that he or she personally saw the
patient, personally performed critical or key portions of
the service, and participated in the a management of the patient.
The teaching physician's note should reference the resident's
note. For payment, the composite of the teaching physician's
entry and the resident's entry together must support the medical
necessity of the billed service and the level of the service
billed by the teaching physician.
AAMC Teleconferences with CMS Staff on the Revisions
On December 17, 2002 and January 9, 2003 the AAMC will be
hosting two teleconferences with CMS staff to discuss the
revisions with members. The teleconferences are open to individuals
who work at AAMC member institutions only. Please note that
AAMC will be collecting member questions about the changes
prior to the call in order to provide CMS staff with the ability
to address members' issues as effectively as possible. There
will also be opportunities to ask questions of CMS staff during
the calls.
If you have questions on the revised CMI, please contact
Denise Dodero, Assistant Vice President, Division of Health
Care Affairs at (202) 828-0493 or ddodero@aamc.org
or Ivy Baer, Director and Regulatory Counsel, Division of
Health Care Affairs, 202-828-0490 or ibaer@aamc.org.
|
