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Field Guide to Physician Coding 3rd Edition



Teaching Physician Rules Primary Care Exception
Citations: CMS Manual, teaching physician rules,
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CMS has developed a specific set of rules for academic settings.  These rules allow a teaching or attending phyisician to bill for services provided jointly by themselves and residents in approved Graduate Medical Education (GME) programs.  Different services (endoscopy, E/M, major surgery) have different requirements for the attending's participation and documentation, in order to bill for the service.

The Primary Care Exception allows the attending to bill for certain, low level E/M services without personally seeing the patient.  The program must provide primary care to pateints, and are typically Family Practice, Internal Medicine, Geriatrics, Pediatrics and OB/GYN.  The program must attest in writing that they meet the requirements, and keep that statement in their files.  The program does not need to send that statement to CMS or to their carrier or MAC.

Only these services are eligible to be billed in this way: 99201--99203, 99211--99213, and the Welcome to Medicare visit.

In order to bill under the primary care exceptin, the teaching physician must:

  • Supervise no more than four residents at a time
  • Not have any other responsibilities during this time
  • Assume responsibility for the care
  • Assure that appropriate treatment is provided
  • Review with the resident during or immediately after every visit the history, exam, diagnosis and treatment plan
  • Document their participation in the review and care provided to every beneficiary

Append modifier GC to claims for services provided under the primary care exception.  This modifier does not affect payment; it is informational only.

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