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Teaching Environment E/M Services

  1. Please define levels of care for E/M services that can be performed by residents in a hospital outpatient setting under the PCE rules.

    Answer: CMS PCE guidelines for the hospital outpatient setting permit a resident who has completed at least six months of training to perform a low‑mid level E/M service under the direct supervision of a TP. The TP must be physically available within the suite, without other simultaneous responsibility and be responsible for supervising no more than four residents per session. The resident’s services may be represented by CPT codes 99201‑99203 and 99211‑99213. PCE guidelines also permit the resident to perform the IPPE and AWVs.

    CMS has limited the PCE levels of care in recognition of the resident’s status as a physician-in-training and the medical necessity of the teaching physician’s role in evaluating and managing clinical problems that demand a more detailed or comprehensive level of care. In the event that a resident identifies the need for a detailed or comprehensive service, he/she must request the teaching physician’s personal supervision and documented presence in order to support the higher-level service as billable to Medicare. Updated 7/12/2018

  2. Why must a teaching physician document a separate note from the resident on a discharge summary? Is it not acceptable to do an attestation on the discharge summary?

    Answer:
    The resident’s service is not billable to Medicare. The attending physician may bill the discharge service to Medicare based on his/her own presence and active participation on the services. An attestation on the discharge summary does not support the attending physician’s presence and participation in the discharge service. Updated 8/29/2017
     
  3. To support billing a hospital discharge (99238‑99239), can the Teaching Attending supervising a resident simply provide an attestation to the resident’s discharge summary?

    Answer:
    Services performed by residents are not billable to Medicare. As for any service being billed by a teaching physician, the billing provider must perform his/her own face-to-face participation in the service and document that service in a note separate from the resident’s note. Updated 6/9/2017
     
  4. Please define what time of night qualifies as a “late night admission” for teaching physician billing.

    Answer:
    CMS does not define a specific time for “late at night”. Reasonably speaking, a late admission may be a patient admitted to the hospital by a resident, late on a given day and not seen until the subsequent day by the attending teaching physician. The attending physician’s note should include an explanation for his/her service taking place on the day after the patient was admitted to inpatient status. Updated 6/9/2017
     
  5. In a teaching facility, if a provider uses the GC modifier should the resident enter documentation in the medical records as well? Or is the GC modifier enough to show that the resident was involved in the care? What is expected in the documentation?

    Answer:
    The resident should document his/her portion of the service and the attending physician should write a separate note, describing his/her portion of the service. The notes, when viewed concurrently, should support the level of care billed by the attending physician. Updated 6/9/2017
     
  6. Is it permissible for a student physician or student NP to document a ROS and/or PFSH?

    Answer:
    While it’s permissible for a student physician or student NP to elicit and document a PFSH and/or ROS, the supervising physician or NP needs to review and corroborate that information, as well as perform the remainder of the E/M visit, in order to bill the service to Medicare. Medicare payment is based on work performed by the attending/billing provider, not on work performed by a student. Updated 6/9/2017
     
  7. In a PCE environment, can a physician supervise residents while also acting as the lead triage for nursing staff? 

    Answer:
    The supervising physician may not have other responsibilities while supervising residents in a primary care exception environment. Acting as a triage for nursing staff would be considered a separate responsibility and, as such, would not be permissible. Updated 6/9/2017
     
  8. Some graduate training programs may require residents to spend two‑three weeks in a primary care setting. Is this allowable under the PCE guidelines?

    Answer:
    In order to comply with PCE rules, the assigned primary care service site must to be located in a hospital or other ambulatory care outpatient setting. PCE rules do not allow for physician supervision of residents  in the office or home visit setting. Please refer to the information provided in Guidelines for Teaching Physicians, Interns, and Residents. (1.3 MB) Updated 6/9/2017
     
  9. Under PCE guidelines, can an E&M service be billed based on time?

    Answer:
    If counseling or coordination of care constitutes > 50% of a clinic visit, the service can be coded based on time. The medical record would need to provide a summary of the counseling and/or coordination details, along with the attending physician’s review, approval or modification of the content. Updated 6/9/2017
     
  10. When a TP in a PCE environment sees a patient with the resident, is that service within PCE guidelines?

    Answer:
    The TP may see clinic patients at the request of a resident, while still fulfilling the supervisory expectation, as long as the TP remains fully available to other residents who are seeing clinic patients at the same time. Updated 6/9/2017
     
  11. In the attestation from the TP, must the TP document separately and give comments on the resident’s note?  Would it be sufficient if the TP simply states that he/she saw and evaluated the patient and agreed with the resident’s documentation, findings and POC?  

    Answer:
    While the entry described above meets the minimal expectation for a TP, NGS encourages documentation of clinical details that can further substantiate the TP’s presence and  full participation in the E/M service. For example: “Patient seen and examined with Dr. Smith. Agree with his finding of aortic murmur and plan for echocardiogram later today.” These details enhance the accuracy of the medical record and will substantiate the service during a possible subsequent Medical Review audit. Updated 6/9/2017
     
  12. Is it appropriate for residents to bill based on time spent counseling and coordinating care?

    Answer:
    Residents cannot bill Medicare for any services. A teaching physician must participate in any service performed by a resident in order to make the service billable to Medicare. As such, time spent by a resident under PCE rules in the outpatient setting may be billable by the teaching physician, but only if all guidelines are met and the teaching physician remains available throughout the service and reviews the resident’s POC. Updated 6/9/2017

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Please define levels of care for E/M services that can be performed by residents in a hospital outpatient setting under the Primary Care Exception (PCE) rules.
Teaching Environment E/M Services
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