5160-4-05 Teaching physician services.

(A) Definitions

(1) "Teaching physician" means a physician (other than a resident) who involves residents in the care of his/her patients.

(2) "Resident" means an individual who participates in an approved graduate medical education (GME) program. The term includes interns and fellows in approved GME programs. A medical student is never considered a resident.

(3) "Teaching setting" means any hospital-based provider setting that receives medicare or medicaid payment for the services of residents under the direct GME payment methodology.

(4) "Student" means an individual who is enrolled in an accredited medical school. A student is never considered to be an intern or a resident.

(5) "Documentation" means notes recorded in the patient's medical records by a resident or teaching physician.

(6) "Physically present" means that the teaching physician is in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.

(7) "Critical or key portions" means that part(s) of a service that is/are a critical or key part of the service. For the purpose of this rule, the these terms are used interchangeably. Critical or key portions means the following:

(a) For anesthesia services, it is the part of the service described in paragraph C)(2) of rule 5101:3-4-21 of the Administrative Code;

(b) For procedures, it means the parts of the service described in paragraph (E)(1)(a) to (E)(1)(h) of this rule;

(c) For evaluation and management services, it means the key portion of the service as defined in paragraph (E)(2)(b) of this rule. This definition does not apply to the evaluation and management codes listed in paragraph (E)(3)(b) of this rule; and

(d) If none of the guidelines in this paragraph apply, the teaching physician determines the critical or key portions of the service.

(8) "CPT or codes" as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.

(B) General reimbursement requirements

Payment may be made directly to the teaching physician for services performed in teaching settings only under the following circumstances:

(1) The covered services are personally performed by a physician who is not a resident in a teaching setting; or

(2) The covered services are provided in a teaching setting jointly by a teaching physician and resident or by a resident in the presence of a teaching physician with certain exceptions listed in paragraph (E)(3) of this rule.

(C) A teaching physician may not be directly reimbursed for direct medical and surgical services if the teaching hospital elects to receive payment for direct medical and surgical services on a reasonable cost basis (expensed on the hospital's cost report).

(D) Documentation

(1) For a teaching physician to be eligible for reimbursement for services, the patient's medical record must document that the requirements for reimbursement as detailed in this rule were met. Documentation may be dictated and typed, hand written, or computer-generated.

(2) The teaching physician must meet the documentation instructions for evaluation and management (E/M) services stated in section 15016 of the medicare carrier's manual (11/2002) including, but not limited to the following requirements:

(a) To be eligible for reimbursement for evaluation and management services, the teaching physician must personally document the following, at a minimum:

(i) A teaching physician performed the service or was physically present during the key or critical portion of the service when performed by the resident;

(ii) Documentation by the resident of the participation and presence of the teaching physician is not sufficient to establish the presence and participation of the teaching physician in the service;

(iii) The participation of the teaching physician in the management of the patient; and

(iv) The combined entries in the medical record by the teaching physician and resident together must document the medical necessity of the service.

(b) Documentation must identify:

(i) The service(s) provided;

(ii) Whether the teaching physician was present during the critical or key portions of the service provided by a resident;

(iii) The participation of the teaching physician in providing the service;

(iv) The combined entries in the medical record by the teaching physician and resident together must document the medical necessity of the service.

(v) The date; and

(vi) A legible signature or identity alone.

(c) Any contribution and participation of a student to the performance of a billable service (other than review of systems and/or past family/social history that 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 requirement set forth in paragraph (B) of this rule. Students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student's documentation of physical exam findings or medical decision making in his or her personal note. If the medical students documents E/M services, the teaching physician must verify and redocument the history of present illness and peform and redocument the physical exam and medical decision-making activities of the service.

(d) The following are examples of unacceptable documentation because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care:

(i) "Agree with above," followed by legible countersignature or identity;

(ii) "Rounded, Reviewed, Agree," followed by legible countersignature or identity;

(iii) "Discussed with resident. Agree," followed by legible countersignature or identity;

(iv) "Seen and agree," followed by legible countersignature or identity;

(v) "Patient seen and evaluated," followed by legible countersignature or identity; and

(vi) A legible countersignature or identity alone.

(E) Special situations

Payment will be made for the services of a teaching physician only if the teaching physician is personally present during all critical or key portion(s) of the service.

(1) Procedures

(a) Surgery

The teaching physician must be present during all critical or key portions of the procedure and must be immediately available to provide services during the entire procedure. The teaching physician is not required to be present during the opening and closing of the surgical area. During the periods of the surgery that are not key portions, the teaching physician must be immediately available to return to the procedure. He/she must not be involved in another procedure from which he/she cannot return.

Documentation of the teaching physician's presence during a surgery, must be documented in the medical record by the physician, resident, or operating room nurse.

In order to bill for two overlapping surgeries, the teaching physician must be present during all critical and key portions of both operations. Therefore, the critical or key portions may not take place at the same time. When all of the critical or key portions of the initial procedure have been completed, the teaching physician may begin to become involved in a second procedure. The teaching physician must personally document in the medical record that he/she was physically present during the critical or key portion(s) of both procedures. The teaching physician may not bill for three or more concurrent surgical procedures. These are classified as a supervisory service to an individual patient and are not payable under the physician fee schedule.

(b) Minor procedures

For procedures that take five minutes or less, the teaching physician must be present for the entire procedure to be considered reimbursable procedures by the department.

(c) Endoscopy procedures

To be considered a reimbursable endoscopy procedure, the teaching physician must be present during the entire viewing including the insertion and removal of the device.

(d) Complex or high-risk procedures

For complex or high-risk procedures such as cardiac catheterization, cardiovascular stress tests, radiologic and cardiologic supervision, and interpretation codes, the teaching physician must be physically present with the resident and must supervise the performance of the procedure or he/she must personally perform the procedure.

(e) Maternity services

In order to be considered a reimbursable service the teaching physician must be present for the delivery. The teaching physician must be physically present for the initial prenatal visit. The teaching physician must also be present during any and all prenatal visits during which there are patient complaints requiring more detailed evaluation, abnormal findings, the need for non-routine testing (e.g. non-routine ultrasonography, fetal monitoring, non stress testing, etc.), or for post date equal to or greater than forty-two week gestation.

(f) Time-based codes

For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made. For example, a code that specifically describes a service from twenty to thirty minutes should only be billed if the teaching physician is present for twenty to thirty minutes. Time spent by the resident in the absence of the teaching physician should not be added to time spent by the resident and teaching physician with the patient or time spent by the teaching physician alone with the patient.

(g) Interpretation of diagnostic radiology and other diagnostic tests

The department will reimburse for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed by a teaching physician.

(h) Psychiatry

Time-based psychiatry codes must meet the requirements in paragraph (E) (1) (f) of this rule. A teaching physician may not add time spent by a resident in the absence of the teaching physician to the total amount of time billed for the service. For certain psychiatric services, the presence of the teaching physician may be met by concurrent observation of the service through the use of a one-way mirror or video equipment. Audio-only equipment does not satisfy the physical presences of the teaching physician.

(i) Anesthesia

The department will reimburse for anesthesia services as outlined in 5101:3-4-21 of the Administrative Code for a teaching anesthesiologist involved in an anesthesia procedure with a resident. The teaching physician must document in the medical records that he/she was present during all critical or key portions of the procedure. The teaching physician's physical presence during only the preoperative or post-operative visits with the patient is not sufficient to receive reimbursement.

(j) Assistants at surgery furnished at teaching hospitals The department will not reimburse for an assistant at surgery in a teaching hospital when a resident qualified to perform the service is available to assist at surgery.

(2) Evaluation and management services

(a) The "documentation guidelines for evaluation and management services" published by the American medical association in the CPT book must be the basis for the selection of the most appropriate level of evaluation and management service.

(b) The teaching physician must be physically present during the medical decision making process.

(c) The teaching physician must personally document his/her presence and participation in the service in the medical records as described in paragraph (D) of this rule.

(d) For evaluation and management services and other services based on time, the teaching physician must be physically present for the entire period of time billed. Time spent by the resident in the absence of the teaching physician is not billable. Examples of codes falling in this category include, but are not limited to, individual psychotherapy codes, critical care services, inpatient neonatal and pediatric critical care services, and evaluation and management codes in which counseling and/or coordination of care is more than fifty per cent of the encounter and time is considered the controlling factor to qualify for that specific code.

(3) Evaluation and management services furnished at primary care centers

(a) The following primary care residency programs qualify for an exception to the teaching physician policies described in paragraph (E)(2) of this rule if the programs attest in writing that they meet all of the conditions in medicare's teaching physician policy as described in 42 C.F.R. 415.174 (10/1/2005). The primary care centers exercising the primary care exception must maintain records demonstrating that they qualify for the exception. Prior approval by the department is not required. The provider must make available a copy of this attestation to the department upon request.

(i) Family practice;

(ii) General internal medicine;

(iii) Pediatrics;

(iv) Obstetrics/gynecology; and

(v) Geriatric medicine.

(b) Payment may be made for the services of teaching physicians provided by residents without the presence of a teaching physician provided that all of the requirements listed in 42 C.F.R. 415.174 (10/1/05) are met. The following lower and mid-level evaluation and management codes may be billed under this exception when provided at a primary care center:

(i) New patient office or other outpatient codes including 99201 to 99203;

(ii) Established office or other outpatient visit codes including 99211 t 99213;

(iii) New patient preventive medicine visits codes including 99381 to 99384;

(iv) Established patient preventive medicine visits including 99391 to 99394; and

(v) Prenatal services billed with the TH modifier and codes 99201 to 99203 or 99211 to 99213 except for those listed in paragraph (E)(1)(e) of this rule.

(c) The services must be furnished in a primary care center located in a hospital outpatient department or another ambulatory care entity in which the time spent by residents in patient care duties is included in the GME payment made to a teaching hospital or hospital's fiscal agent.

(d) When a resident is assigned to a physician's office away from the hospital or primary care center where he/she is assigned or is making home visits, the primary care center exception does not apply and teaching physician services are not billable. In this situation, the physician's office where the resident is assigned should bill for services provided.

(F) Modifiers

To bill for services provided by a teaching physician that meet all the provisions of this rule, the following modifiers must be used to bill for services:

(1) To bill for services performed in part by a resident under the direction of a teaching physician, use modifier "GC."

(2) To bill for services performed by a resident without the presence of a teaching physician under the primary care exception rule described in paragraph (D)(E)(3) of this rule, use modifier "GE."

Effective: 02/12/2006
R.C. 119.032 review dates: 09/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 9/1/89, 1/1/01, 9/1/05