Billing and documentation guidelines are not the same in all 50 states. A statement such as, “I saw and evaluated the patient. I agree with the resident’s documentation,” may be acceptable in some states, but in other states, the Medicare Administrative Contractor (MAC) would consider this to be a generic attestation, and require the teaching physician to personalize the documentation to the specific patient and define the teaching physician’s role in the plan.
CMS does not require the teaching physician to see every Medicare patient. Based on the experience level of the resident, it is not always necessary for the teaching physician to render services when the resident has already seen the patient. However; some MACs require more than a generic attestation (“macro” or “smart phrase”) to support the teaching physician’s services. The statement, “I saw and evaluated the patient with the resident,” is an acceptable smart phrase for the teaching physician to use in the electronic health record, if the teaching physician adds patient-specific details of the plan in submitted documentation.
Examples of unacceptable teaching physician documentation:
- “Agree with above.”, followed by legible countersignature or identity.
- “Rounded, Reviewed. Agree.”, followed by legible countersignature or identity.
- “Discussed with resident. Agree.”, followed by legible countersignature or identity.
- “Seen and agree.”, followed by legible countersignature or identity.
- “Patient seen and evaluated.”, followed by legible countersignature or identity.
Keep in mind, the level of E/M billed should reflect what was medically necessary for the patient, and not necessarily the level required and documented for teaching purposes.
Medical Student Involvement
A teaching physician may only use the medical student’s review of systems and past family/social history. A teaching physician may not use a teaching physician attestation when working with a medical student.
Examples of accepted smart-phrases for teaching medical students:
- “I have reviewed and confirmed the review of systems and past/family and medical history as documented by the medical student.”
- “I have reviewed and confirmed the review of systems and past/family and medical history as documented by the medical student, however; it is also noted that … (provider fills in further details as appropriate).”
There are specific requirements the teaching physician must meet when billing for critical care. Key elements that must be documented include:
- The time the teaching physician spent providing critical care
- That the patient was critically ill during the time the teaching physician saw the patient
- What made the patient critically ill
- The nature of the treatment and management provided by the teaching physician
The medical review criteria are the same for a teaching physician as they are for all other physicians.
CPT explains that the level of certain E/M services must be selected using time as the determining factor if over 50 percent of the total visit time was spent in counseling or coordinating care. Note, however, that some MACs and even private insurers may no longer accept documentation of a “50 percent” statement and total visit time. Some payers require two specific times to be documented in the medical record: the time spent counseling and the total time of the visit.
Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching physician as critical care or other time-based services, Time spent teaching my not be counted towards critical care time. Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted when reporting a time based code. The teaching physician must be present for the entire period of time for which the claim is made. The teaching physician’s documentation should only identify their total visit time (spent on the unit/floor for inpatient services), including face-to-face time with the patient. The teaching physician must meet the minimum time requirements before a time-based service can be reported.
For example: 99239 (discharge day management >30 minutes) requires the teaching physician to provide care for at least 31 minutes. Similarly, 99291 (critical care service, first hour) is reported after 30 minutes of qualifying critical care service provided by the teaching physician.
For minor surgical procedures (lasting less than five minutes), the teaching physician must be physically present during the entire service. For major procedures (lasting more than five minutes), the teaching physician must be physically present during the “key portion(s)” of the service and must be immediately available to furnish service during the entire procedure. The teaching physician must document the extent of his/her participation.
Billing Misc. Procedures
Examples of resident’s involvement in a family medicine practice:
A family medicine resident sees an established patient for follow-up of his hypertension and to receive a knee injection to relieve pain cause by osteoarthritis. The resident documents the encounter, including the injection administration. The attending documents, “I saw and examined the patient. I agree with the resident’s note.”
In this case you may be able to bill the visit to your MAC, as doesn’t require a personalized teaching physician note, however, you cannot bill the injection because the teaching physician does not state that he or she was present for the injection.