Lack of a teaching physician statement in a patient’s record can lead to denied services.
A teaching physician’s statement must explain who rendered the service as well as if he/she was physically present during the furnished service. The record must always explain the teaching physician’s participation in the management of the patient’s care. Reviewers can and will pull both the teaching physician’s and resident’s documentation to compare that both records include the required explanations. Both entries should be filed together and support medical necessity for all services rendered. In the absence of a resident’s documentation, the teaching physician must document according to that of a non-teaching setting.
Who can provide the billable services?
In most cases, the history and physical must be performed by the teaching physician. If the resident provides any part of the billable service, the teaching physician must be physically present and the documentation must support such a presence. If the resident documents services performed on their part, the teaching physician needs to at least verify in their own notes the documentation provided by the resident.
What are the exceptions?
Residents with a minimum of 6 months within a GME approved residency program may provide some EM services without the direct presence of their teaching physician. Those EM services include: 99201, 99202, 99203, 99211, 99212, 99213, G0402, G0438, and G0439.
The supervising physician billing for these resident rendered services cannot be responsible for more than 4 residents at the time at any services are being performed independently by their residents. The supervising physician must always be in such a proximity that enables their immediate presence if necessary for the performing resident. While services are rendered by the resident, the teaching physician must also be without other responsibilities, must have have primary care designation for the patient being treated, ensure medical necessity of all rendered services, and review all care immediately before and after it is provided. The teaching physician’s documentation must include their personal review of the patient’s medical history, the resident’s findings on physical examination, diagnosis, as well as treatment plan.
Exceptions within Primary Care Centers
Residents independently providing primary care to patients can do so if the patient considers the facility their center for primary care. The resident is expected to provide care to the same general group of established patients throughout their program.
Overall, qualifying services that can be provided by residents independently and within the guidelines described above are: unproblematic acute care, chronic care for ongoing conditions, coordination of care appointed by other providers, and/or comprehensive care not limited by organ system or diagnosis. Practices most likely to qualify for programs where residents can perform care within these exceptions include family practice, general internal medicine, geriatric medicine, pediatrics, and obstetrics/gynecology.
For further reference, a pdf download from the CMS Claims Processing Manual is provided here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf . The specific breakdown of the above guidelines and requirements as well as a variety of examples of documentation that would and would not be accepted are found in 100.1.1.