Teaching Physician Rules

Definition:

The teaching physician (TP) rules describe a payment method by which Medicare pays an attending physician or teaching physician for services performed jointly with an intern, resident, or fellow, in an approved graduate medical education program (GME). The teaching physician’s presence and participation is required.

Medical students are never considered residents and are not covered under the teaching physician rules.

Teaching physician services are billed using the attending physician or teaching physician's provider number and the documentation of the resident and the teaching physician are combined to select the service code.

Resident’s responsibility:

• date all entries into the medical record,
• indicate specialty in the heading of your note, such as cardiology fellow note, or internal medicine visit.
• Document services personally performed,
• legibly sign the note.
• If signature is not legible, print name below the note.

Evaluation and Management (E/M) Services provided jointly with a resident when TP and resident see patient at the same time:

Scenario:
 

The resident obtains the history and documents the exam while the teaching physician is in the room with the resident.  The resident writes the note.

What must the TP do and document?

The teaching physician must show that he/she saw the patient, performed key or critical components of the service personally, and participated in the management of the care.
E/M services performed jointly with a resident when the TP and the resident see the patient at different times:

Scenario:

The resident and the TP each see and examine the patient at different times.

What must the TP do and document?

The teaching physician must obtain history, perform key or critical portions of the exam, and participate in the plan of care. The TP must personally document a note that legibly references the resident's note. It must demonstrate a physical presence, patient evaluation, and participation in the plan of care.

EXAMPLES OF STATEMENTS LINKING TP NOTE TO RESIDENT NOTE
"I saw and evaluated the patient. Discussed with resident, Dr. Joshua and agree with his findings and plans as documented in his notes."

"See cardiology resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plan as written."

"I saw and examined the patient. Agree with cardiology resident's note, except murmur louder so check echo."

"I saw and evaluated the patient. Agree with internal medicine resident's note, except picture more consistent with pericarditis. Begin NAsAIDS."

What do these examples have in common?

• The teaching physician references the resident's notes,
• The note demonstrates that the TP saw the patient
• The notes shows that the TP is involved in the plan of care.  

Minor Surgical Procedures

Minor procedures, defined as those which take less than five minutes, have their own rules.

• The teaching physician must be present the entire time.
• The resident or nurse may document the teaching physician's presence.

Major surgical procedures.

Major surgical procedures require the TP’s presence during key or critical portions of the procedure.

• The teaching physician must document their presence during the key and critical component of the procedure.
• The teaching physician must be immediately available for the entire procedure.
• The TP determines which parts of the procedure are key/critical.

Teaching physician rules for endoscopy:

• The teaching physician must be present in the room for the entire procedure from the time the scope is inserted to the time the scope is removed.  (Scope in/scope out)
• The TP should document their participation in the care.

Teaching physician rules based on time, including critical care (99291 --99292) prolonged services (99354 to 99359), discharge day management (992238—99239).

• Only the TP time is counted, not the resident’s time.  The TP should personally document his/her time in the record.

E/M services based on time

When counseling dominates the E/M service, and time is used to select the E/M code, use only the TP time.

Critical care billing  

The teaching physician must be present for the entire period of time for which the claim for payment is made.  Resident time does not count towards the critical care time.

• The teaching physician must personally see the patient and spend more than 30 minutes of critical care time.
• The TP must perform a critical care service and must participate in the management of the care.
• The resident's note may serve to add detail to the nature of the patient's illness, the treatment provided and the critical condition of the patient.
• Count only the TP time for billing.

Anesthesia services.  

For anesthesia services, teaching physician must document their presence during the critical or key portions of the procedure.  In addition,

• The teaching physician must prescribe the anesthesia plan and participate in the induction and emergence.
• The teaching physician is responsible to insure that all anesthesia procedures are performed by a qualified person and monitor anesthesia administration frequently.
• The TP must remain present for immediate diagnosis and treatment of all emergencies.

Primary care exception

This primary care exception allows residents who have been in residency for longer than six months to see patients in a primary care practice under the supervision of the TP, but without the requirement that the TP see each patient.

• The teaching physician may only supervise four or fewer residents at a time and
• must be immediately available to provide assistance.
• The teaching physician may not have other responsibilities at that time and
• must have primary responsibility for those patients treated by the residents in the primary care program.
• The teaching physician must review care provided during or immediately after the patient's seen.
• The teaching physician must document his or her whole participation himself and review the management of each patient.

The billing for this is limited to 99211—99213 (established patients, level 1-3) 99201—99203 (new patients, level 1-3), and the Welcome to Medicare visit (G0344).

Medical student, nurse practitioner students and physician assistant students
 
Students are not covered under the teaching physician rules, and their services may not be billed jointly by a teaching physician.

Only the review of systems and the past, medical family and social history may be documented by a student of any kind.

• Either the resident or the teaching physician must document the history of the present illness, must personally perform the examination, and must document the assessment and the plan.
• In order to count the review of systems and past medical, family and social history performed by the student, the resident or TP must link that documentation to their own, noting that it was reviewed.
• Procedures performed by a student are never billable.