Medicare reimbursement for physician services in teaching settings is contingent on satisfying certain supervision and documentation requirements. Specifically, to receive Medicare Physician Fee Schedule (PFS) payment for services provided in a teaching setting, services must be furnished by:
- A physician who is not a resident;
- A resident, with a teaching physician physically present during critical or key portions of the service; or
- A resident, under a primary care exception within an approved GME program.
A previous GME@Dentons article, "The 'Primary Care Exception' -- a limited opportunity for billing without in-person supervision of residents", addressed the third scenario. Under the primary care exception, a teaching physician is allowed to bill under the PFS for low- and mid-level evaluation and management (E/M) services provided by residents in approved graduate medical education (GME) programs, if the services are furnished in certain primary care centers.
This article addresses the PFS payment requirements related to the second scenario, in which the resident performs elements required for a given service either jointly or in the presence of the teaching physician.
To receive payment under the PFS, both the teaching physician and the resident must document the service. Additionally, the teaching physician must personally document:
- That he or she performed or was physically present during the key or critical portions of the service when performed by the resident; and
- That he or she participated in the management of the patient. The claim the teaching physician submits must include the GC modifier, which indicates that the service was performed in part by a resident under the direction of a teaching physician. Together, the teaching physician's and the resident's medical record entries must support the medical necessity of the service.
In a scenario in which a resident admits a patient, but the teaching physician is not available to see the patient until the following day, the teaching physician may refer to the resident's note instead of re-documenting the medical history, exam, and other information recorded by the resident, to the extent that the patient's condition has not changed and the teaching physician concurs with the resident's record. The teaching physician is responsible for amending the resident's note to reflect changes in the patient's condition, clinical course, and new information obtained when the teaching physician sees the patient. The date of service on the teaching physician's bill should be the date he or she first saw the patient, even if the combined record with the resident is necessary to support the higher level of service.