- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD-ROM
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
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 months of a GME approved residency program.
- Teaching physicians submitting claims under this exception may not supervise more than four 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
Reviewed 11/6/2023