Teaching Physician Rules

October 15th, 2015 - Betsy Nicoletti
Categories:   Medicare  
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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:



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?

Minor Surgical Procedures

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



Major surgical procedures.

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

Teaching physician rules for endoscopy:

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


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.

Anesthesia services.  

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


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 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.

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