Primary Care Exception Guidelines

Services performed by attending physicians at teaching hospitals, in collaboration with house staff in an approved GME program, generally require evidence of direct care by the attending physician in order to meet Medicare billing guidelines. CMS allows for a variance in these requirements, defined as the Primary Care Exception, and this article defines the rules and circumstances in which services may be billed.

In certain primary care centers, residents may provide E&M services in the absence of a teaching physician, when the following guidelines are met and fully documented in the associated medical records:

• The site of care is a primary location for health care service. Qualifying residency programs include family practice, general internal medicine, geriatric medicine, pediatrics, and obstetrics/gynecology. Psychiatry programs furnishing comprehensive care may also qualify.
• Services are in the low-mid range for new and established patients (99201-99203, 99211-99213), or defined as the IPPE (IPPE: G0402) or the AWV (AWV: G0438)
• For this exception to apply, a center must attest in writing that all the following conditions are met for a particular residency program. This attestation may be submitted via the NGSConnex portal, using the “My Financials” tab and the “Other” selection in the Audit and Reimbursement drop down box.”
• Prior approval by the MAC is not necessary. Centers exercising this exception must maintain records demonstrating that all CMS-defined criteria are fully met and documented.
• Qualifying locations include hospital outpatient departments or ambulatory care entities, where the time spent by residents in patient care is included in determining direct GME payments to a teaching hospital. This requirement is not met when the resident is assigned to a physician’s office away from the center or makes home visits. In the case of a nonhospital entity, verify with the MAC that the entity meets the requirements of a written agreement between the hospital and the entity set forth at 42 CFR 413.78(e)(3
• Residents providing billable care in these circumstances must have completed at least six (6) months of a GME approved residency program.
• Teaching physicians submitting claims under this exception may not supervise more than four (4) residents at any given time and must provide direction from a proximity that allows immediate availability to the residents.
• Teaching physicians may not have other responsibilities while supervising the residents, including the supervision of other personnel, and must maintain the primary medical responsibility for patients whom the residents are treating.
• Teaching physicians must ensure that the care provided by each resident is reasonable and necessary and review the care (history, examination, diagnosis, treatment plan) during or immediately following each visit, and document their review in each medical record.

Related Content

• Full description of Primary Care Exception rules: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 100.1.1.C  (1024 KB)