Table of Contents Forward... 1 Introduction... 2 Evaluation and Management Services... 3 Psychiatric Services... 6 Diagnostic Surgery and Surgery...

Table of Contents Forward... 1 Introduction... 2 Evaluation and Management Services... 3 Psychiatric Services... 6 Diagnostic Surgery and Surgery... 6 Other Complex or High Risk Procedures... 7 Radiology, Pathology and Other Diagnostic Tests... 8 Anesthesia... 9 Time Based Codes... 10 Moonlighting Residents... 10 Services Furnished in a Non-Provider Setting... 11 Modifiers to be Used When Reporting Teaching Physician Services... 11 Glossary of Terms... 12 PBS Responsibilities for Claims Review and Verification... 13 Questions & Answers... 14

Forward The purpose of this manual is to enable physicians to understand the Pennsylvania Blue Shield concept of a teaching setting and teaching physician and to assist them in observing the requirements for proper documentation of services provided in a teaching setting. This manual is also intended as a reference for administration and medical record room personnel to enable them to comply effectively with these requirements. It is the responsibility of Pennsylvania Blue Shield to monitor compliance with these requirements. This manual will acquaint Healthcare Professionals and their staffs with the documentation requirements of Pennsylvania Blue Shield. Every service submitted for payment must be documented in the patient s record. This includes diagnostic tests, medical care, surgery and any other services eligible for payment by Pennsylvania Blue Shield. These guidelines concerning physician documentation of services provided in a teaching setting will apply to all Pennsylvania Blue Shield indemnity programs, as well as any Highmark whollyowned programs. 1

Introduction This booklet is intended to provide the basic criteria for distinguishing those physician services furnished in a teaching setting that may be billed to Pennsylvania Blue Shield on a 1500 claim form. The guidelines contained in this manual are effective July 1, 1996, for our indemnity programs and April 1999, for Highmark wholly-owned managed care products. In a teaching setting, physician services provided to individual patients are considered to be the payment responsibility of Pennsylvania Blue Shield. Conversely, physician services that are furnished for the general benefit of patients (i.e., supervising and teaching of residents); are considered to be services to the hospital. For a service to be billable on a 1500 claim form, it must meet the requirement of being an identifiable physician service to an individual patient. Services that are furnished by the resident or by the teaching physician for the general benefit of patients cannot be billed on a 1500 claim form. Practices vary widely among and within teaching hospitals with respect to the degree of physician involvement in the care of patients. In some cases, teaching physicians personally direct residents in furnishing patient care services. In others, residents assume a greater degree of responsibility for the care patients receive, and the teaching physicians exercise only general control over the residents activities. The most important consideration in determining if the services of a teaching physician are eligible to be billed on a 1500 claim form is the presence of the teaching physician during the key portion of any service or procedure for which payment is sought. This physical presence requirement identifies situations when the teaching physician is sufficiently involved in the service, and at the same time it provides a standard that can be readily documented and verified. If the requirements which are outlined in this manual are met, payment may be made under the circumstances described, to a teaching physician through Pennsylvania Blue Shield as identifiable physician services to individual patients. 2

Evaluation and Management Services In the case of evaluation and management services (for example, visits and consultations), the teaching physician must be present during the portion of the service that determines the level of service billed and must personally document his or her participation in the service in the medical records. For a given encounter, the selection of the appropriate level of E/M service should be based on the Documentation Guidelines for Evaluation and Management Services developed by the American Medical Association (AMA) and HCFA and published by the AMA. If a teaching physician documents his or her presence and participation in the E/M service, the level of service may be selected based on the extent of history obtained and/or examination performed and/or the complexity of the medical decision making required and documented in his or her personal entry in the medical record which may include references to notes entered by the resident. If the medical decision-making in an individual service is highly complex to an inexperienced resident, but straightforward to the teaching physician, the appropriate level of service to be billed should reflect the involvement of the teaching physician in the service. It is the teaching physician s decision if he or she should perform hands-on care, in addition to the care furnished by the resident in his or her presence. However, in the case of both hospital inpatient and outpatient evaluation and management services, the teaching physician must be present during the key portion of the visit. If the teaching physician believes that a key portion of an entire evaluation and management service cannot be identified, then he or she should be present for the entire service. The documentation requirements for some common clinical situations for teaching physicians are illustrated below: Illustration 1 - All required elements are obtained personally by the teaching physician without a resident present. In this situation, a resident may or may not have performed an independent service. If no resident has seen the patient, the physician should document on the same basis he or she would document an E/M service in a nonteaching setting. If a teaching physician s service follows a resident s service, then the teaching physician s documentation should refer to the resident s note and provide summary comments that establish, revise, or confirm the resident s findings and the appropriate level of service required by the patient. For example, the teaching physician would not have to restate the review of systems and family social history in the case of an initial hospital service. However, the teaching physician would have to examine and question the patient to verify the key findings of the resident s notes since he or she was not present during the resident s interaction with the patient. 3

Illustration 2 - All required elements are obtained by the resident in the presence of, or jointly with, the teaching physician and documented by the resident. In this situation, the resident s note may document the teaching physician s direct observation, performance, and personal input into the key elements. The teaching physician s personal documentation may be limited; at a minimum, it must include a confirmation of each component of the resident s documentation and the teaching physician s presence during the service. The combination of entries must be adequate to substantiate the level of service required by the patient. Illustration 3 - Selected required elements of the service, for example, history and physical examination are obtained by the resident independently. The teaching physician repeats the key elements of the examination. These elements are discussed with the teaching physician either prior to or after the teaching physician s personal service. In this situation, the resident s note may document the teaching physician s input into the history and medical decision-making. The teaching physician s note must include summary comments that revise or confirm the findings of the resident s physical examination and discussion of the history and medical decision-making. The combined entries must be adequate to substantiate the level of service required by the patient and billed. There is one exception to the physician presence requirement. Under this exception, Pennsylvania Blue Shield may be billed via the 1500 claim form for reasonable and necessary low to mid-level evaluation and management services, when furnished by a resident without the presence of a teaching physician, if all of the following criteria are met: 1. 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 is included in the hospital s full time equivalent count of residents. This requirement is not met when the resident is assigned to a physician s office away from the center or makes home visits. 2. Any resident furnishing the service without the presence of a teaching physician must have completed more than six (6) months of an approved residency program. The center is responsible for furnishing this information to Pennsylvania Blue Shield upon request. 3. The teaching physician may not direct the care of more than four (4) residents at any given time and must direct the care from such proximity as to constitute immediate availability. The teaching physician must: Have no other responsibilities at the time; Assume management responsibility for those patients seen by the residents; Ensure that the services furnished are appropriate; 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 4

Document the extent of his or her own participation in the review and direction of the services furnished to each patient. 4. The range of services furnished by residents in the center include all of the following: Acute care for undifferentiated problems or chronic care for ongoing conditions including chronic mental illness. Coordination of care furnished by other physicians and providers. Comprehensive care not limited by organ system or diagnosis. 5. The patients seen must be an identifiable group of individuals who consider the center to be the continuing source of their health care and in which services are furnished by residents under the medical direction of teaching physicians. Although the residents must generally follow the same group of patients throughout the course of their residency program, the teaching physicians need not remain the same over any period of time. This exception to the teaching physician presence applies to only specific low and mid-level evaluation and management codes for both new and established patients. The new patient codes to which the exception applies are CPT codes 99201, 99202, and 99203 (and their successor codes). Established patient codes to which the exception applies are CPT codes 99211, 99212, and 99213 (and their successor codes). The teaching physician must be present for higher level evaluation and management codes and all invasive procedures. For this exception to apply, a center must attest in writing that all of the preceding conditions are met for a particular residency program. The attestation statements for this exception should be sent to: Manager Pennsylvania Blue Shield Benefits Cost Management Senate Plaza, 4W P.O. Box 890089 Camp Hill, PA 17089-0089 5

Psychiatric Services The teaching physician will be considered to be present during each visit for which payment is sought, as long as the teaching physician observes the key portion of the visit through a visual device (i.e., a one-way mirror, video equipment, etc.) and documents the medical record accordingly. Audio-only equipment does not meet this exception to the physical presence requirement. Further, the teaching physician supervising the resident must be a physician, i.e., the teaching physician policy does not apply to psychologists who supervise psychiatry residents in approved GME programs. In the case of evaluation and management procedures, the teaching physician must personally document his or her presence and participation in the service in the medical records. The teaching physician s supervision and the resident s therapy session must be conducted simultaneously. Additionally, the teaching physician must be present for the length of time of the time based therapy billed. For example, if the teaching physician only watched a 15 minute portion of a 30 minute session through a one way mirror, only 15 minutes could be billed, not the entire half hour. Diagnostic Surgery and Surgery In order for the teaching physician to be eligible for payment of diagnostic surgical and surgical procedures, he or she must be present during all critical and key portions of the service. A discussion of the findings with a resident would not be sufficient. In the case of procedures performed through an endoscope, the teaching physician must be present during the entire viewing. The entire viewing includes insertion and removal of the device. Viewing of the entire procedure through a monitor in another room does not meet the teaching physician presence requirement. The teaching physician must be in a position where he or she can influence the process and must document his or her observations during the endoscopy. In the case of surgery (including endoscopic operations), the teaching surgeon is responsible for the preoperative, operative, and post-operative care of the patient. The teaching surgeon may determine which post-operative visits are to be considered key and require his or her presence. The teaching physician must be present during all key portions of the surgery. During non-key portions, the teaching physician must be immediately available to return to the operating room or must designate another teaching physician to be immediately available. The teaching physician may be involved in two (2) overlapping procedures. However, the teaching physician presence requirement is not met when he or she is required in two places for concurrent surgeries. For example, the teaching physician may finish up key portions of one procedure and then move on and start another procedure. 6

Single Surgery - When the teaching surgeon is present for the entire period between the opening and closing of the surgical field, his or her presence may be demonstrated by notes in the medical records made by the physician, resident, or operating room nurse. For purposes of this teaching physician policy, there is no required information that the teaching surgeon must enter into the medical records if his or her name appears as primary surgeon on the operative report and he or she signs that report. Two overlapping surgeries - In order to bill for two overlapping surgeries, the teaching surgeon must be present during the key portions of both operations. Therefore, the key portions may not take place at the same time. When all of the key portions of the initial procedure have been completed, the teaching surgeon may begin to become involved in a second procedure. The teaching surgeon must personally document the key portion of both procedures in his or her notes in order that a reviewer may clearly infer that the teaching physician was immediately available to return to either procedure in the event of complications. In the case of three concurrent surgical procedures, the role of the teaching surgeon (but not anesthesiologist) in each of the cases is classified as a supervisory service to the hospital and is not billable to Pennsylvania Blue Shield as a physician service to an individual patient. Minor procedures - For procedures that take only a few minutes to complete, e.g., simple suture, and involve relatively little decision making once the need for the operation is determined, the teaching surgeon must be present for the entire procedure in order to bill for the procedure. Other Complex or High Risk Procedures In the case of complex or high-risk procedures for which Pennsylvania Blue Shield s policy or the CPT description indicates that the procedure requires personal (in person) supervision of its performance by a physician, Pennsylvania Blue Shield should only be billed when the teaching physician is present with the resident. The presence of the resident alone would not meet the teaching physician presence requirement necessary for these services. Examples of these procedures include: Interventional radiologic and cardiologic supervision and interpretation codes Cardiac catheterization Cardiovascular stress tests Transesophageal echocardiography 7

Radiology, Pathology and Other Diagnostic Tests The physician, who is also in a supervisory capacity, need not be present during the actual performance of a radiology, pathology or other diagnostic test in order to bill for the interpretation of the test. The physician may submit a claim for payment of the interpretation when he or she reviews the film, specimen, or study with the resident or by performing an independent interpretation, as long as the following criteria are met: 1. The service must be personally provided for an individual patient by the physician. 2. The service must contribute directly to the diagnosis or treatment of an individual patient. 3. The service ordinarily requires the performance and exercise of medical judgment by a physician. 4. The service provided for the patient must be meaningful from the standpoint of affecting the course of treatment and not merely a routine review of a report for purposes of quality control, authorization, validation or teaching. 5. The interpretation must result in a written report prepared for inclusion in the patient s medical record. If the teaching physician s signature is the only signature on the interpretation, we will assume that he or she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the image, specimen, or study and the resident s interpretation and either agrees with it in whole or makes comments to edit those findings and then signs his or her own note. A countersignature alone of the resident s interpretation by the teaching physician is not acceptable documentation. Clinical pathology consultation services must meet the following requirements: 1. Be requested by the patient s attending physician. The term attending physician is used to denote any physician involved in the treatment of the patient. 2. Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient. 3. Result in a written narrative report included in the patient s medical record. 4. Require the exercise of medical judgement by the consultant physician. 8

Anesthesia In order for a teaching physician who provides anesthesia services in a teaching hospital to receive payment from Pennsylvania Blue Shield, he or she must: 1. Prescribe the anesthesia plan. 2. Personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence. 3. Ensure that any procedure in the anesthesia plan that he or she does not perform is performed by a qualified individual. 4. Monitor the course of anesthesia administration at frequent intervals. 5. Remain physically present and available for immediate diagnosis and treatment of emergencies. The teaching physician must direct no more than four (4) anesthesia procedures concurrently and cannot perform any other service while he or she is directing the concurrent procedures. If the teaching physician is involved in furnishing more than four (4) procedures concurrently, or is performing other services while directing the concurrent procedures, the concurrent anesthesia services are considered to be physician services to the hospital and should not be billed to Pennsylvania Blue Shield on a 1500 claim form. Effective January 1, 1996, a teaching physician will be reimbursed as if he or she personally performed the service, if he or she is involved in a single anesthesia procedure involving a single resident. In order to receive payment as if he or she personally performed the service, the physician cannot perform services involving other patients during the period the anesthesia resident is furnishing services in a single case. If the teaching physician who provides anesthesia services is present for the entire period from induction to emergence, there is no required information that the teaching anesthesiologist must enter into the medical record if his or her name appears on both the anesthesia and operative reports and he or she signs the anesthesia report. However, if the teaching anesthesiologist is involved in two, three or four concurrent anesthesia procedures, documentation must appear in the medical record of his or her presence during induction, emergence and any other portion of the procedure when he or she is present and participated in the case. A signature alone on the anesthesia report would not be considered adequate documentation. The resident or other staff may document in the anesthesia report on behalf of the teaching physician indicating the teaching physician s presence during the key portions of each case. The teaching physician s presence is not required during the pre-operative or post-operative visits withthe patient. 9

Time Based Codes For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made. For example, a code that specifically describes a service for 20 to 30 minutes is only payable when the teaching physician is present for 20 to 30 minutes. Do not add time spent by the resident in the absence of the teaching physician to: time spent by the resident and teaching physician with the patient; or, time spent by the teaching physician alone with the patient. Examples of codes falling into this category include: Psychotherapy Psychiatric Therapy Critical Care Services E/M Codes in which counseling and/or coordination of care dominates (more than 50 percent) the encounter, and time is considered the key or controlling factor to qualify for a particular E/M service. Prolonged services In-patient discharge codes Anesthesia Moonlighting Residents The term services of moonlighting residents refers to services that licensed residents perform outside the scope of an approved GME program. The following criteria must be met in order to bill for moonlighting services: 1. The services are identifiable physician services. 2. The resident is fully licensed to practice medicine, osteopathy, dentistry or podiatry by the State in which the services are performed. 3. The services can be separately identified from the services that are required as part of the approved GME program. (Contracts and agreements must be available for review to ensure compliance.) If the above criteria are met, the following situations could qualify for payment under Pennsylvania Blue Shield as moonlighting services of interns or residents. 1. Services of residents that are not related to their approved GME programs and are performed in an outpatient department or emergency department of a hospital in which they have their training program. 10

2. When an intern or resident is in an approved GME program at one hospital and is concurrently furnishing moonlighting services in another hospital that lacks an approved GME program, the services in the second hospital may be billed. 3. The intern or resident moonlights in another teaching hospital and sufficient information can be furnished to be sure that the moonlighting resident is not being included in the residency count of either hospital for the period of time in question. Services of residents to inpatients of hospitals in which the residents have their approved GME program are not billable to Pennsylvania Blue Shield. Additionally, services of a teaching physician associated with moonlighting services should not be billed. Services Furnished in a Non-Provider Setting If a non-provider entity, such as a freestanding family practice or multi-specialty clinic is not under the sponsorship of a hospital and the residents are not included in any hospital s full-time equivalent count of residents, the residents services may be billed as physician services to Pennsylvania Blue Shield. In order to bill in this manner, the resident must be fully licensed to practice medicine, osteopathy, dentistry or podiatry in the State in which the service is performed. These services may be billed as physician services regardless of whether a resident is functioning within the scope of his or her GME program in the non-provider setting. Under these circumstances, the resident is functioning in the capacity of a physician, and, consequently, no bill can be submitted for services of a teaching physician. Modifiers to be Used When Reporting Teaching Physician Services The following modifiers must be used when reporting teaching physician services on a 1500 claim form: GC - GE - This service has been performed in part by a resident under the direction of the teaching physician. This service has been performed by a resident without the presence of a teaching physician under the primary care exception. 11

Glossary of Terms Approved Graduate Medical Education (GME) program - a residency program approved by the Accreditation Council for Graduate Medical Education of the American Medical Association, by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association, by the Council on Dental Education of the American Dental Association, or by the Council on Podiatric Medicine Education of the American Podiatric Medical Association. Non-provider setting - a setting other than a hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility in which residents furnish services. These include, but are not limited to, family practice or multi-specialty clinics and physician offices. Resident - (1) an individual who participates in an approved GME program, including programs in osteopathy, dentistry and podiatry. (2) a physician who is not in an approved GME program, but who is authorized to practice only in a hospital, for example, individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools. (The term resident is synonymous with the terms intern and fellow.) Teaching hospital - a hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry or podiatry. Teaching physician - a physician (other than another resident) who involves residents in the care of his or her patients. Teaching setting - any hospital department, skilled nursing facility or satellite clinic where time is spent in patient care activities by residents who are included in the hospital s full time equivalent count of residents. 12

PBS responsibilities for claims review and verification Pennsylvania Blue Shield is responsible for ensuring that the claims being submitted are prepared with an understanding of the conditions governing payment for physician services in a teaching setting. Reviews are conducted on a post-payment review basis: to determine that physicians are in compliance with these requirements; for correction of any documentation deficiencies; and for recovery of funds paid for improperly billed services. The provision of personal and identifiable services must be substantiated by adequate record notations entered personally by the physician in the chart. Pennsylvania Blue Shield is responsible for making appropriate checks of a patient s records and for reviewing admission, progress, discharge notes, reports, etc., to verify that all services meet the appropriate coverage criteria. If that review shows that services have been paid which are not documented according to Pennsylvania Blue Shield requirements, those payments will be considered overpayments and will have to be refunded. Additionally, teaching physicians who are found to be billing for services that are not documented, may be required on subsequent claims to submit documentation for their covered services for review prior to payment. 13

Questions & Answers 1. Q. What type of GME programs qualify for the exception concerning evaluation and management services? A. We believe that the types of GME programs most likely to qualify for this exception include: family practice and some programs in general internal medicine, geriatrics, pediatrics, and obstetrics/gynecology. Certain GME programs in psychiatry may qualify in special situations such as when the program furnishes comprehensive care for chronically mentally ill patients. These would be centers in which the range of services the residents are trained to furnish and actually do furnish include comprehensive medical care as well as psychiatric care. For example, antibiotics are being prescribed as well as psychotropic drugs. 2. Q. The guidelines concerning the exception to the physician presence requirement, state that the teaching physician may not direct the care of more than four (4) residents at any given time. Could this requirement be met if the teaching physician was directing the care of 2 residents, 1 physician assistant and 1 certified registered nurse practitioner? A. No, the physical presence exception would not apply. The teaching physician, in this instance, would have to adhere to the regular guidelines under evaluation and management services identifying the key portion. 3. Q. When the teaching physician was present during the key portion of a service, does his countersignature of the resident s notes in the medical record provide adequate documentation for the teaching physician to bill Pennsylvania Blue Shield on a 1500 claim form? A. A countersignature alone does not document that a physician was present during the key portion of the service. Although it is not necessary for the teaching physician to repeat all of the documentation entered into the medical record by the resident, the teaching physician should enter additional notes to indicate his or her involvement in the service. 4. Q. Can a teaching physician bill on a 1500 claim form if he or she is present during the key portion of a service performed by a third or fourth year medical student? A. A medical student is never considered to be a resident. However, if the medical student contributes to the performance of a service or procedure which is billed, that contribution must be performed in the physical presence of a physician or jointly with a resident in a service which meets the requirements for teaching physician billing. 5. Q. If the resident notes in his or her documentation, that he or she is rounding with Dr. X or currently being supervised by Dr. X, is it acceptable for the teaching physician to use a stamp which states Seen, examined and agree with Dr. Resident, and to sign after the stamp? 14

A. This is not acceptable. If the teaching physician is visiting patients during grand rounds, this is considered to be a teaching service and no 1500 claims should be submitted. The documentation needs to show the service is separate and identifiable. The note in the patient s medical record must support the presence, activity and involvement of the teaching physician. The key elements and the presence and the involvement of the teaching physician should be reflected in the medical record, in such a way, that it would be clear to anyone who looked at the medical record, at a later date, that the involvement of the teaching physician justified the service which was billed. 6. Q. With regard to Psychiatry, how many residents can an attending physician simultaneously supervise via video, on-line equipment? A. A teaching physician cannot be adequately involved with an individual patient to qualify for billing on a 1500 claim form, if he or she is involved with multiple patients simultaneously. If the teaching physician is simultaneously supervising more than one resident via video equipment or a similar device, these services would be considered to be services furnished for the general benefit of patients, and therefore, considered to be services to the hospital. 7. Q. What documentation is required by the teaching physician when a resident is involved in a consultation? A. The documentation guidelines which apply to evaluation and management services, are also applicable to consultations. The teaching physician must be present during the key portion of the service and should document his or her participation in the consult. The level of service to be billed is based on the extent of history obtained, and/or examination performed, and/or the complexity of the medical decision making required and documented in the medical record, which may include references to notes entered by the resident. The particular consultation code to be billed (whether it is a regular consult code or a confirmatory consult code), would be based on the teaching physician s involvement. Additionally, a request for a consultation must come from the teaching physician. Although the resident may initially request the consultation, the need for the consult must be confirmed/requested by the teaching physician. (The teaching physician s level of decision making may not necessitate a consult.) 8. Q. Just what does any teaching physician who meets the physical presence and documentation requirements for a service can bill for that service mean? Is any defined as all physicians within the same group practice, regardless of medical specialty? Or, is any defined as all physicians within the same group practice and of the same medical specialty? For example: can a General Surgeon attending be responsible for an Internal Medicine resident? 15

A. Any teaching physician, regardless of medical specialty, who is medically responsible for the services the resident is furnishing to the patient, and who meets the necessary requirements, can bill Pennsylvania Blue Shield on a 1500 claim form. 9. Q. If a resident performs critical care services for a patient, and the teaching physician is present and involved during the key portion of the services being performed, can the teaching physician bill for the total duration of critical care time that the resident was in attendance with the patient? A. Critical care services are time based services, and therefore, can only be billed using the time that the teaching physician was in actual attendance in work related to the individual patient s care. When a bill is submitted for any procedure code determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made. For example, a procedure code that specifically describes a service of from 20 to 30 minutes, should only be billed if the teaching physician is present for 20 to 30 minutes. Do not add time spent by the resident in the absence of the teaching physician to: time spent by the resident and the teaching physician with the patient; or time spent by the teaching physician alone with the patient. 10. Q. In the case of critical care, what is the appropriate way to document time? Is the statement I spent X amount of time which included... acceptable? Do you want to see a start and stop time? Will you accept the time documented by the nurse in the nurse s notes and not by the physician? A. If the service is furnished in the teaching setting, the physician must indicate in the chart the amount of time he or she was present furnishing or supervising critical care services to the patient. The problem with relying on nurse s notes in such situations is that, in locations in which there are multiple patients, it might not always be clear to the nurse which patient the physician is treating. 11. Q. May a teaching surgeon bill on a 1500 claim form for surgical procedures performed by third or fourth year residents, when the teaching physician is in the operating suite rather than in the operating room? A. No, this is not appropriate as the physical presence during key portions requirement cannot be met. If the teaching physician believes the third or fourth year resident is capable of performing surgical procedures without his presence, the supervisory service is considered a teaching service and not a physician service to an individual patient. 12. Q. What is required of the teaching physician to be eligible to bill minor procedures? A. In order for the teaching physician to bill for minor procedures, he or she must be present during the key portion of the procedure. In the case of minor procedures, the key portion is, in fact, the procedure itself. Consequently, the teaching physician must be physically present during the entire procedure. 16

13. Q. Won t these documentation rules restrict the independent experience for residents in accordance with Residency Review Committee (RRC) requirements? A. Graded, independent experience for residents in accordance with Residency Review Committee requirements, is not being restricted by these guidelines. However, it does mean that the teaching physician may want to forgo billing to allow a resident total independence in delivering a service when appropriate during the training period. 14. Q. Are electronic signatures acceptable on reports of diagnostic tests? A. Electronic signatures are acceptable on reports of diagnostic tests. However, in teaching settings, if the resident prepares and signs the interpretation, the teaching physician must indicate in a separate identifiable note that he or she has personally reviewed the image, specimen or study and either agrees with or edits the findings. Additionally, documentation concerning security and integrity controls must be available for review. 15. Q. Are computer-generated test results, interpretations and reports acceptable? A. Because there is markedly reduced demand on the physician s time where computer interpretation is involved, the attending physician should review the information and write any additional comments on the report. If a resident signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the results and the resident s interpretation and either agrees with it in whole or makes comments to edit those findings and then signs his or her own note. A teaching physician s countersignature alone, of the resident s, or a computer generated interpretation, is not acceptable documentation. 16. Q. Are signature stamps in the medical record acceptable? A. No, the use of a signature stamp is not acceptable as it leaves doubt as to who used it and therefore who authored the note. 17. Q. If it is found that an overpayment has been made in connection with the services of a physician in a teaching setting, who is responsible for repayment? A. The ultimate responsibility for the overpayment falls on the physician in whose name the claim was made. Repayment by another party would, of course, satisfy the claim for overpayment. But, if no repayment is made, legal action, if it occurs, would be against the physician. Proper documentation in the hospital records of the rendition of services is, therefore, in the physician s interest. 17

PBPD 10/00