Title/Description: Documentation and Billing for Professional Services Rendered by Teaching Physicians

Transcription

1 University of Kentucky / UK HealthCare Policy and Procedure Policy # A Title/Description: Documentation and Billing for Professional Services Rendered by Teaching Physicians Purpose: To comply with CMS Guidelines when billing for services performed by physicians in teaching settings. Policy Definitions Approved Graduate Medical Education (GME) Program Resident Medical student Teaching physician Teaching hospital Teaching setting Critical or key portion Documentation Macro Physically present or physical presence Direct supervision Immediately available Participation in management of the patients care Procedure Medical Students Evaluation & Management Services (E/M) Primary Care Exception Teaching physicians submitting claims under this exception must: Time-Based Codes Surgical Procedures (Including Endoscopic Operations) Definition of Immediate Availability to Return to the Operating Room Overlapping Cases Minor Procedures Postoperative Visits Other Complex or High-Risk Procedures Anesthesia Limit on Concurrent Anesthesia Cases and Activities Endoscopy Interpretation of Radiology and Other Diagnostic Tests Interpretation of Diagnostic Radiology and Other Diagnostic Tests Psychiatry Maternity Services Renal Dialysis Services Modifier GC Services Provided by Residents and Fellows Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 1

2 Residents/Fellows Not in Approved Programs Fellows Moonlighting at a UK HealthCare Facility Persons and Sites Affected Policies Replaced Effective Date Review/Revision Dates Policy In billing for physician services, the University of Kentucky follows the regulations promulgated by the Centers for Medicare and Medicaid Services (CMS) in 42 CFR through 42 CFR , Subpart D, Physician Services in Teaching Settings (the Teaching Physician Regulation), regardless of payer, unless and to the extent the University and a payer may have agreed in writing to an exception to such regulations. All faculty and other physicians employed by the University shall adhere to this policy and the Teaching Physician Regulations when involving any resident in patient care, regardless of whether such resident is included as an eligible individual in the full-time equivalency count in any Medicare Part A cost report submitted by the University. Neither this policy nor the Teaching Physician Regulation applies to services performed in conjunction with advanced practitioners. If a resident participates in a service furnished in a teaching setting, the University (or Kentucky Medical Services Foundation, Inc.) shall submit a claim for payment for physician services only if: 1. The services are personally furnished by the physician who is not a resident, or the teaching physician is present during the key portion of the service or procedure for which payment is sought; 2. The medical record documents that the teaching physician was present when the service was furnished or that the teaching physician saw and participated in the management of the patient, referencing the residents note, making appropriate changes based on personal assessment; and 3. All other requirements for billing for physician services as set forth in applicable law, regulations, and policy are met. Definitions The following terms used in this policy have the meanings assigned to such terms. Other capitalized terms used but not defined in this policy have the meanings assigned to such terms in the Teaching Physician Regulation. Approved Graduate Medical Education (GME) Program Approved Graduate Medical Education (GME) Program means a residency program approved by the Accreditation Council for Graduate Medical Education (ACGME) of the American Medical Association or the equivalent entity for osteopathy, dentistry, or podiatry or a program Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 2

3 that may count towards certification of the participant in a specialty or subspecialty listed in the Annual Report by the American Board of Medical Specialties (ABMS). Resident Resident means an individual who participates in an approved GME program, including programs in osteopathy, dentistry and podiatry. This includes interns and fellows. Resident also includes a physician who is not in an approved GME program, but who is authorized to practice only in a hospital setting, such as physicians with a residency training license in Kentucky. Medical student Medical student means individuals who participate in an accredited educational program that is not an approved GME program. Students, including acting interns, are never considered to be interns or residents. Teaching physician Teaching physician means a non-resident physician or dentist who involves residents in the care of his or her patients. Teaching hospital Teaching hospital means a hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry or podiatry. Chandler Hospital, including Kentucky Children s Hospital, and UK HealthCare Good Samaritan Hospital are teaching hospitals. Teaching setting Teaching setting means any setting in which Medicare payment for resident services is made under Part A direct GME payment and a resident participates in the delivery or documentation of services. All hospital and ambulatory facilities owned and/or operated by the University of Kentucky are considered teaching settings. Critical or key portion Critical or key portion means that part (or parts) of a service or procedure that the teaching physician determines is (are) a critical or key portion(s). These terms are often used interchangeably. Documentation Documentation means notes regarding the service furnished as recorded in the patient s medical record by a resident and/or teaching physician or others as outlined in specific situations. Documentation may be dictated and typed, handwritten or computer generated, and typed or handwritten. Documentation must be timed and dated and include a legible signature or identity 1. Documentation must identify, at a minimum, the service and evidence of teaching physician presence and participation in the management of the patient. 1 Documentation is required to be timed in hospitals and in hospital-based or provider-based settings under the CMS Conditions of Participation for Hospitals and by The Joint Commission accreditation standards. Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 3

4 Macro A macro is a command in a computer or dictation application that automatically generates predetermined text that is not edited by the user. When using an electronic medical record, the teaching physician may use a macro as the required personal documentation if the teaching physician adds it personally in a secured (password protected) system. In addition to any teaching physician s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. It is considered insufficient documentation if both the resident and the teaching physician enter text only by macros in the electronic medical record. Signature stamps and preprinted statements on paper forms are unacceptable forms of teaching physician documentation. Also see Policy A05-080, Electronic Medical Record Authentication. Physically present or physical presence Physically present or physical presence means that 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. Direct supervision Direct supervision means the teaching physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the service. It does not mean that the teaching physician must be present in the room when the service is performed. Immediately available Immediately available has not been defined by CMS. However, CMS has stated that a teaching physician who is performing another service or procedure is not immediately available. In addition, UK HealthCare has concluded that certain other situations do not meet the definition of immediately available (See Surgical Procedures (Including Endoscopic Operations). Participation in management of the patients care Per CMS transmittal 2303 dated Sept. 14, 2011, teaching physicians may follow a late night admission by a resident and document they saw the patient and participated in the management of the patient. Procedure Medical Students Any contribution of a medical student to the performance of a service billable by a teaching physician must be performed in the physical presence of a teaching physician or jointly with a resident in a service meeting the requirements set forth below. Students may document services in the medical record; however, the teaching physician may only refer to the student s documentation of an Evaluation & Management (E/M) service that is related to Review of Systems and Past/Family/Social History. Any additional documentary contribution by the Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 4

5 medical student may not be considered as supporting documentation for the teaching physician s professional charges unless elements are personally repeated by the physician. Evaluation & Management Services (E/M) Teaching physicians must be physically present during critical or key portion(s) of the services that a resident performs. Teaching physicians need not repeat documentation already provided by a resident but must, at a minimum, document in the medical record: 1. That they performed the service or were physically present during the critical or key portion(s) of the service when it was performed by the resident; and 2. Their participation in the management of the patient. When these two requirements are met, notes made by the resident combined with documentation by the teaching physician must substantiate the level of service billed. Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician. The following scenarios are taken directly from the CMS Guidelines and describe clinical situations in which E/M services may be provided by teaching physicians. Each scenario is followed by examples of what would be considered appropriate documentation by the teaching physician. 1. 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 normally document an E/M service in a non-teaching setting. Documentation examples of Scenario 1 (a) Admitting Note: I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident s note and agree with the documented findings and plan of care. (b) Follow-up Visit: Hospital Day #3. I saw and evaluated the patient. I agree with the findings of the plan of care as documented in the resident s note. (c) Follow-up Visit: Hospital Day #5. I saw and examined the patient. I agree with the resident s note except the heart murmur is louder, so I will obtain an echo to evaluate. 2. 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. Documentation examples of Scenario 2: Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 5

6 (a) Initial or Follow-up Visit: I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident s note. (b) Follow-up Visit: I saw the patient with the resident and agree with the resident s findings and plan. 3. 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 the critical or key portions of the service, and participated 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 of the billed service and the level of the service billed by the teaching physician. Documentation examples of Scenario 3: (a) Initial or Follow-up Visit: I saw and evaluated the patient. Discussed with resident and agree with resident s findings and plan as documented in the resident s note. (b) Follow-up visit: See resident s note for details. I saw and evaluated the patient and agree with the resident s findings and plans as documented. ; or (c) Follow-up Visit: I saw and evaluated the patient. Agree with resident s note but lower extremities are weaker, now 3/5; MRI of left side spine today. 4. Scenario 4: When a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day: The teaching physician must document that he/she personally saw the patient and participated in the management of the patient. The teaching physician may reference the resident's note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient's condition has not changed, and the teaching physician agrees with the resident's note. The teaching physician's note must reflect changes in the patient's condition and clinical course that require that the resident's note be amended with further information to address the patient s condition and course at the time the patient is seen personally by the teaching physician. The teaching physician s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making regardless of whether the combination of the teaching physician s and resident s documentation satisfies criteria for a higher level of service. 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. Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 6

7 The following are examples of Unacceptable Documentation: 1. Agree with above followed by legible countersignature or identity; 2. Rounded, Reviewed, Agree followed by legible countersignature or identity; 3. Discussed with resident. Agree followed by legible countersignature or identity; 4. Seen and agree followed by legible countersignature or identity; 5. Patient seen and evaluated followed by legible countersignature or identity; and 6. A legible countersignature or identity alone. Such documentation is unacceptable, because it is not possible to determine from the documentation whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care. Primary Care Exception For certain office visits (such as CPT , ; G0402-Medicare IPPE; Medicare Annual Wellness visits G0438 G0439; and for Kentucky Medicaid only) the teaching physician is not required to see the patient, but rather need only be immediately available when a resident performs these services in order for the teaching physician to bill for his/her service. Prior to applying this exception, a primary care center must attest in writing to the Corporate Compliance Office that it meets the following requirements for billing under the Exception. Furthermore, the department must maintain documentation on file at all times to support compliance with these requirements. 1. The services must be furnished in a center located in the outpatient department of a hospital or another ambulatory care entity in which the time spent by residents in patient care activities is included in determining direct GME payments to a teaching hospital by the hospital s fiscal intermediary. This requirement is not met when the resident is assigned to a physician s office away from the center or makes home visits. 2. Residents furnishing E/M services without the presence of a teaching physician must have completed more than six months of an approved residency program. 3. The residents must generally follow the same group of patients throughout the course of their residency program. 4. The range of services furnished by residents includes all of the following: (a) Acute care for undifferentiated problems or chronic care for ongoing conditions including chronic mental illness; (b) Coordination of care furnished by other physicians and providers; and (c) Comprehensive care not limited to organ system or diagnosis. 5. The teaching physician in whose name the payment is sought must not supervise more than four residents at any given time and must direct the care from such proximity as to constitute immediate availability. Teaching physicians may include residents with less than 6 months in a GME approved residency program in the mix of four residents under the teaching physician s supervision. However, the teaching physician must be physically present Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 7

8 for the critical or key portions of services furnished by the residents with less than 6 months in a GME approved residency program. That is, the primary care exception does not apply in the case of residents with less than 6 months in a GME approved residency program. Teaching physicians submitting claims under this exception must: (a) Have no other responsibilities at the time of the service for which payment is sought; (b) Assume management responsibility for those patients seen by the residents; (c) Ensure that the services furnished are reasonable and necessary; (d) Review with each resident during or immediately after each visit the patient s medical history, physical examination, diagnosis and record of tests and therapies; and (e) Personally document the extent of his/her participation in the review and direction of the services furnished to each patient; e.g. I have discussed this case with Dr. (Resident s name) and agree with findings and plans as documented. 2. Patients seen must be an identifiable group of individuals who consider the center to be their continuing source for health care. 3. The modifier GE must be submitted on the claim. If, during the care provided, a more complex problem arises that requires the personal participation of the teaching physician, the teaching physician may bill for a more complex level of care (level IV or V) if warranted. The teaching physician is required to document his or her presence during and participation in the critical or key portions of the service. Time-Based Codes For procedure and E/M codes determined on the basis of time, the teaching physician must be physically present for the entire time period for which the claim is made. The time spent by the resident without the teaching physician s presence may not be included in determining what level of time-based code to bill. Examples include but are not limited to: 1. Individual medical psychotherapy; 2. Critical care services; 3. E/M visits in which counseling and/or coordination of care dominates more than 50% of the encounter; 4. Discharge day management over 30 minutes; 5. Prolonged services; and/or 6. Care Plan Oversight. Surgical Procedures (Including Endoscopic Operations) To bill for surgical, high risk, or other complex procedures, including surgical endoscopy, the teaching physician must be present during all critical and key portions of the procedure and must be immediately available to furnish services during the entire procedure. In the case of surgery, the teaching physician s presence is not required during the opening and closing of the surgical field unless these activities are considered to be critical or key portions of the procedure. If the teaching physician is not immediately available to return to the Operating Room, he or she must Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 8

9 arrange for another qualified surgeon to be immediately available to assist with the procedure if needed. The teaching physician must document the specific key portions for which he or she was present, as well as document his/her immediate availability for participation in the procedure. This applies to single cases and overlapping cases, e.g., I was present for incision, debridement and wound repair, and was immediately available throughout the case. Definition of Immediate Availability to Return to the Operating Room CMS has not defined what constitutes immediate availability. However, UK HealthCare has determined that in the following scenarios the physician is not immediately available as required by CMS: 1. When the physician is responsible for three operating rooms at the same time (this is also not billable time); 2. While the physician is seeing patients in a regularly scheduled clinic; 3. When the physician is performing a procedure in an outpatient or clinic setting; 4. When the physician is responsible for a case in the VA operating room; and 5. When the physician is responsible for any other "scheduled" patient care (urgent/emergent cases are an exception). Conservative judgment should always be used. In all cases, the teaching physician must be able to return to the case or arrange for another teaching physician to cover for him/her. The medical record shall note which physician is immediately available. Overlapping Cases The teaching physician may not bill for more than two overlapping cases. To bill for two overlapping surgeries, the teaching physician must be present during the critical or key portions of both operations. The critical or key portions of each case must not take place simultaneously. When all key portions of the initial case have been completed, the teaching physician may become involved in the second case. The rules for immediate availability to return to the operating room still apply. When the teaching physician cannot remain immediately available to both cases, he/she must arrange for another qualified surgeon to be immediately available to assist residents should the need arise. The teaching physician must personally document in the medical record that he/she was physically present during the key portion(s) of both procedures and who was immediately available to assist. Minor Procedures For procedures that take only a few minutes (5 minutes or less) and involve relatively little decision-making, the teaching physician must be present for the entire procedure and must document his/her presence in the medical record. Postoperative Visits The teaching physician will determine which postoperative visits are considered key and require his/her presence. When applicable, it is expected that the teaching physician will make at least one postoperative visit prior to discharge and one postoperative visit in the follow-up clinic in order to bill the full surgical fee. Documentation must support the teaching physician s presence and participation in post-operative care. Note: under the Behavioral Standards in Patient Care, Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 9

10 the attending physician shall visit the patient at least once a day on an inpatient basis to answer questions, to clarify the patient s care plan, and to advise the patient and family of the patient s daily progress as well as of major decisions, unless the attending and the patient agree in advance that a daily visit is not necessary. If the teaching physician does not personally participate in postoperative care, the operative procedure should be billed with the modifier -54 for surgical care only. Other Complex or High-Risk Procedures In the case of complex or high-risk procedures for which national Medicare policy, local policy, or the CPT description indicates that the procedure requires personal (in person) supervision of its performance by a physician, the teaching physician must be present throughout the procedure in order to bill. Examples include interventional radiologic and cardiologic supervision and interpretation codes, cardiac catheterization, cardiovascular stress tests, and trans-esophageal echocardiography. The teaching physician must document his/her presence or participation in the procedure. If the teaching physician personally performs the entire procedure without a resident present and personally documents his/her own procedure note, a separate presence statement is not required as part of the documentation.assistants at Surgery An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure. No payment is allowed for services of assistants at surgery when furnished in a teaching hospital that has a training program related to the medical specialty required for the surgical procedure and when a qualified resident is available. In circumstances where there is no qualified resident available, claims may be submitted with the modifier -82, indicating that a qualified resident was not available, or by completing the Assistant Surgeon Certification Statement provided by Kentucky Medical Services Foundation. The medical record must contain documentation that indicates that a qualified resident was unavailable to assist in the case. Exceptions: Payment may be made, even if there is a qualified resident available, under exceptional circumstances (for example, emergent, life-threatening situations such as multiple trauma requiring immediate attention). Payment may be made for the services of assistants at surgery in teaching hospitals if the primary surgeon has a policy of not using residents in connection with his/her surgical procedures (including preoperative and post-operative care). Complex medical procedures, including multistate transplant surgery and coronary bypass, may require a team of physicians who each perform a unique, discrete function requiring special skills integral to the total procedure. In such instances, each physician is engaged in a level of activity different from assisting the surgeon in charge of the case. If payment is made on the basis of a single team fee, additional claims are denied, and team surgery is paid for on a By Report basis. In other situations, the services of physicians of different specialties may be necessary during surgery due to multiple medical conditions. For example, a patient s cardiac condition may require a cardiologist to be present to monitor the patient s condition during abdominal surgery. In this situation, the physician furnishing the concurrent care is functioning at a different level than that of an assistant at surgery. Payment would be based on the regular fee schedule value for this concurrent care. Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 10

11 Anesthesia It is the responsibility of the teaching physician to be present in the operating room for all key portions of a procedure including, if applicable, induction and emergence. He or she must be immediately available throughout the entire case. He or she may not participate in activities that restrict availability to participate in non-critical portions of a service that develop into critical portions of the service (for example, emergency, complications, and change in the patient s condition). Teaching physician presence during all key portions, as well as what the specific key portions of the service were, must be documented in the patient s medical record in all cases. When a teaching physician is involved with one resident in a single case or two concurrent cases, the teaching physician must personally document in the medical record that he or she was present during all critical or key portions of the anesthesia service, and was immediately available to furnish services throughout the entire service or procedure for each case. For example, I was present for induction and emergence and immediately available throughout the case. Modifiers AA and GC shall be appended to the claim. The teaching physician s services are billed as Medical Direction when the teaching physician is involved in the oversight of a resident or certified registered nurse anesthetist in up to four concurrent anesthesia cases. Faculty members should not be scheduled to direct anesthesia at more than two anesthetizing locations simultaneously when a resident is involved. A teaching physician may be scheduled to direct anesthesia in up to four anesthetizing locations simultaneously when a certified nurse anesthetist is involved. Modifier QK shall be appended to the claim during these cases. Medical Direction is met when a teaching physician: (a) Performs a pre-anesthetic examination and evaluation; (b) Prescribes the anesthesia plan; (c) Personally participates in the most demanding procedures in the anesthesia plan including, if applicable, induction and emergence; (d) Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual; (e) Monitors the course of anesthesia administration at frequent intervals; (f) Remains physically present and available for immediate diagnosis and treatment of emergencies; and (g) Provides post-anesthesia care as indicated. The teaching physician must personally document in the medical record that he or she performed the pre-anesthetic exam and evaluation, provided the post-anesthesia care, and was present during the most demanding procedures, including induction and emergence, where applicable. When Medical Direction is performed by more than one teaching physician, each teaching physician must personally document his or her presence during specific services and the specific services he or she performed. The teaching physician who started the case shall bill the service. Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 11

12 Limit on Concurrent Anesthesia Cases and Activities A teaching physician providing Medical Direction in concurrent cases cannot ordinarily be involved in furnishing additional services to other patients. However, the teaching physician may address an emergency of short duration in the immediate area, administer an epidural or caudal anesthetic to ease labor pain, or periodically (rather than continuously) monitor an obstetrical patient. These activities do not constitute a separate service for the purpose of determining whether the Medical Direction criteria are met. Further, while directing concurrent anesthesia services, a teaching physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment. If the teaching physician leaves the immediate area of the operating suite for other than short durations, or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the teaching physician s services to the surgical patients are supervisory in nature and are not billable as Medical Direction. Endoscopy To bill for endoscopic procedures (excluding surgical endoscopy described above), the teaching physician must be present during the entire viewing. Viewing starts at the time of insertion of the endoscope and ends at the time of removal of the endoscope. Viewing the entire procedure through a monitor in another room does not meet the presence requirement. The teaching physician must document that he or she was present throughout the entire viewing, including insertion and removal. Interpretation of Radiology and Other Diagnostic Tests The teaching physician may bill for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician. If a resident prepares and signs an interpretation, the teaching physician must personally review the image and the resident s interpretation, and document that he or she personally reviewed the image and the resident s interpretation and either agrees or disagrees with it or edits the findings. A countersignature by the teaching physician on the resident s interpretation is not sufficient documentation. Interpretation of Diagnostic Radiology and Other Diagnostic Tests Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician. If the teaching physician s signature is the only signature on the interpretation, Medicare assumes that he/she is indicating that he/she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the resident s interpretation and either agrees with it or edits the findings. Medicare does not pay for an interpretation if the teaching physician only countersigns the resident s interpretation. Psychiatry For psychiatric services furnished under an approved GME program, the requirement for the presence of the teaching physician during the service may be met by concurrent observation of the service through use of a one-way mirror or video equipment. Audio-only equipment does not meet this exception. The teaching physician supervising the resident must be a physician. This Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 12

13 teaching physician policy and the Teaching Physician Regulation do not apply to psychologists who supervise residents in an approved GME program. Maternity Services To bill for a delivery, a teaching physician must be present for the delivery and must document his/her presence and participation in the delivery. For Kentucky Medicaid and all other payers, the teaching physician must be present for the key portions of the delivery (e.g. placenta removal, repair of birth trauma, etc). Renal Dialysis Services The teaching physician may count face-to-face visits provided by residents toward the monthly capitated payment (MCP) if he or she is physically present during the visit. The teaching physician may utilize the resident s notes. However, he or she must document his/her physical presence during the visit(s) furnished by the resident and document his/her review of the resident s notes. For example, I was present for this dialysis session, reviewed the resident s note, and agree with the note as documented. Modifier GC A "GC" modifier must be added to all services when residents are involved in providing care with a teaching physician. Services Provided by Residents and Fellows The rules on billing by teaching physicians when services involve residents apply equally to services involving fellows. Except as described below, a resident or fellow may not bill in the Medicare program in his/her own name, regardless of whether the teaching hospital included the resident/fellow in its cost of full-time equivalents for its cost report. Residents/Fellows Not in Approved Programs 2 If the resident/fellow is not in an approved program, typically he or she may bill for services in his/her own name in any provider setting provided that the resident/fellow is a duly licensed physician in the State and has a provider number. Fellows Moonlighting at a UK HealthCare Facility Under certain circumstances it may be permissible to bill for fellows moonlighting in an approved program. Medicare will not allow such billing if the fellow is moonlighting in the home institution of his or her training program. Other payor rules vary, however. Therefore, clarification should be obtained from Kentucky Medical Services Foundation, Inc. (KMSF) before billing any other payors. In addition, appropriate approvals shall be obtained by the Residency Program Director, GME Office, Chief Medical Officer, Risk Management Committee, and KMSF. 2 An approved program is a program accredited through the American College of Graduate Medical Education or the American Board of Medical Specialties. Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 13

14 Persons and Sites Affected Enterprise Chandler Good Samaritan Kentucky Children s Ambulatory Department Policies Replaced Chandler HP Good Samaritan Kentucky Children s CH Ambulatory KC Other UK HealthCare A Effective Date: 7/10/2015 Review/Revision Dates: 10/1/2010, 7/10/2015 Approval by and date: Signature Date Name Shelby Gorman, Director of Compliance and Coding, Kentucky Medical Services Foundation, Review Team Leader Signature Name Colleen Swartz, Chief Nurse Executive Signature Name Marcus Randall, MD, Chief, Ambulatory Services Signature Name Bernard Boulanger, MD, Chief Medical Officer Signature Name Anna L. Smith, Chief Administrative Officer Signature Name Michael Karpf, MD, Executive Vice President for Health Affairs Date Date Date Date Date Policy # A Documentation and Billing for Professional Services Rendered by Teaching Physicians 14