Posted by: Sarah Cartwright
Academic Emergency Medicine
Billing for Services With/Without Resident Involvement
Teaching physicians manage a myriad of documentation issues in their busy teaching programs. Much of the guidance is vague at best and often there is no one individual assigned to manage the regulatory, documentation and coding issues associated with a busy academic program. There are numerous significant elements required to manage these aspects in an academic center and often the practice plan looks at more generalized issues rather than those specific to emergency medicine. With Medicare, Medicaid and numerous private payers establishing the more stringent rules, attention to the various CMS transmittals is necessary. More and more the private payers are looking at medical necessity, acuity and documentation to reduce their costs as well as control the volume of their subscribers who go to the emergency department.
Many academic centers follow Medicare guidelines for all payers to control risk and succeed. However, for those payers who pay according to their own specific requirements, a little extra attention goes a long way. The industry is currently under siege from payers who want to determine payment and medical necessity from final diagnosis rather than the presenting problem which has been mandated through EMTALA and prudent layperson. Thus, without a robust denials management program and ongoing provider education, the academic practice will certainly lose revenue until national and/or state legislative action assures fair payment for emergency services.
As of 2021, Medicare will pay for Evaluation and Management (E&M) teaching physician services furnished in a teaching setting under the Medicare Physician Fee Schedule (MPFS) only if the services are furnished:
- The teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident, and
- The participation of the teaching physician in the management of the patient is clearly documented.
The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.
For payment, the composite of the entries in the medical record by must support the medical necessity of the billed service and the level of the service billed under the teaching physicians name and UPIN number. In the absence of a note by a resident, the teaching physician must document as he or she would document an E/M service in a non-teaching setting. In this circumstance, the teaching physician personally performs all the requirements of an E/M service.
Resident Performs Service in Presence of TP
When 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 this service, notes by residents, nurses or physicians 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.
Resident Performs Service in Absence of TP
When the resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his or her service and the teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and discusses the case with the resident, the teaching physician, resident, student or nurse may document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient.
Medicare adjusted these regulations to provide that a physician, resident, or nurse may
document in the patient’s medical record that the teaching physician presence and participation requirements were met. As a result, for E/M visits furnished beginning January 1, 2019, the extent of the teaching physician’s participation in services involving residents may be demonstrated by notes in the medical records made by a physician, resident, student or nurse.
Medicare explicitly names PA and NP, CNS, CNM and CRNA students as APRN students, along with medical students, as the types of students who may document notes in a patient’s medical record that may be reviewed and verified rather than re-documented by the billing professional
For purposes of payment, the teaching physician must at a minimum sign and date documentation prepared by a resident, nurse or student. The presence and participation of the teaching physician in the management of the patient must be documented; “…the clinician may review and verify (sign/date) notes in a patient’s medical record made by other physicians, residents, nurses, students, or other members of the medical team, including notes documenting the practitioner’s presence and participation in the services, rather than fully re-documenting the information.”
Please note that there has NOT been any change to WHAT must be documented in the medical record. The recent CMS changes only address WHO can document the services provided in the medical record.
Medicare clearly states, “We also noted that, while the proposed change addresses who may document services in the medical record, subject to review and verification by the furnishing and billing clinician, it would not modify the scope of, or standards for, the documentation that is needed in the medical record to demonstrate medical necessity of services, or otherwise for purposes of appropriate medical recordkeeping.”
In addition, CMS has now made it clear that the new documentation policy applies broadly to all services of physicians, PAs and NPs regardless of the type of service furnished (e.g., E/M, procedure, or diagnostic test) by clarifying, “… our proposed medical record documentation policy would apply broadly to all services of physicians, PAs and APRNs, regardless of the type of service (E/M, procedure, diagnostic test) or the setting in which the service is furnished.”
Reference: 2019 CMS Final Physician Fee Schedule
Taken all together, although no change has been made to the documentation requirements for the Emergency Medicine E/M codes 99281-99285, CMS has certainly provided some relief as to the extent of the teaching physician attestation required. In transmittal 4283, CMS also eliminated all of the previous examples of “acceptable” and “unacceptable” documentation. ACEP offers the following sample attestation when supervising a resident for your consideration:
I, Dr. X, personally saw the patient, performed critical or key portions of the service, and discussed the care with the resident.
For documentation performed by OTHER than the TP, Edelberg recommends that all elements of the history, physical examination and medical decision making as well as TP presence during the key elements of procedures must be documented in the chart by other physicians, residents, nurses, students, or other members of the medical team as long as the teaching physician agrees with the documentation by others as above. Note: for timed procedures, only the time spent by the TP may be used for billing purposes and must be documented by any one of the above to be considered for payment.
For payment, the composite of the teaching physician’s entry and the entries of others as listed above must support the medical necessity of the services provided and the level of the service billed by the teaching physician. The above attestations would cover E/M services in addition to any procedures or diagnostic tests.
Documentation may be dictated, typed, hand-written, or computer-generated. Documentation must be dated and include a legible signature or identity. Pursuant to 42 CFR 415.172 (b), documentation must identify, at a minimum”
- the service furnished, the participation of the teaching physician in providing the service, and whether the teaching physician was physically present.
- When using an electronic medical record, it is acceptable for the teaching physician to use a macro for documentation if the teaching physician adds it personally in a secured (password protected) system as long as the macro contains personalized information pertinent to the patient’s treatment.
- 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 patient on the specific date of service. It is insufficient documentation if both the resident and the teaching physician only use generic macros.
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 may not be counted towards critical care time. Only time spent by the teaching physician personally caring for the patient or together with a resident or individually may be counted when reporting a time-based code.
Per Medicare, “Any contribution and participation of students to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decisionmaking activities of the E/M service being billed but may verify any student documentation of them in the medical record, rather than re-documenting this work.”
- Medicare Claims Processing Manual. Chapter 12 – Physicians/Nonphysician Practitioners
(Rev. 10742, 05-03-21). Chapter 100
- CMS Manual System Department of Health & Human Services (DHHS). Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS): Transmittal 4283 Date: April 26, 2019: Change Request 11171
- American College of Emergency Physicians. FAQs. https://www.acep.org/administration/reimbursement/reimbursement-faqs.