Teaching Physician Attestations – Procedures
When involving residents in the care of patients, teaching attendings must demonstrate that the appropriate level of supervision was provided for each type of procedure or service performed. The focus of this article is to narrow down on what the attendings are required to say (demonstrate) in their medical record documentation to meet these requirements.
Anesthesia
Single Resident/Single Procedure – The teaching physician must document that he/she was present during all critical (or key) portions of the procedure. Medicare pays these services, unreduced.
Medical Direction – When an anesthesiologist is involved in concurrent procedures with more than one resident, or with a resident and a non-physician anesthetist, Medicare pays for the anesthesiologist’s services as medical direction. The teaching anesthesiologist must document his/her involvement in cases with residents.
Diagnostic Procedures
Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician.
- If the teaching physician’s signature is the only signature on the interpretation, Medicare assumes that he/she is indicating that he/she personally performed the interpretation.
- If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the resident’s interpretation and either agrees with it or edits the findings.
- Medicare does not pay for an interpretation if the teaching physician only countersigns the resident’s interpretation.
- Example: I have personally reviewed the CT scan, reviewed the Dr. Cho’s (resident) interpretation and agree with his findings.
Endoscopy Procedures
The teaching physician must be present during the entire viewing.
- Viewing starts at the time of insertion of the endoscope, and
- Viewing ends at the time of removal of the endoscope
- Viewing of the entire procedure through a monitor in another room does not meet the teaching physician presence requirement
- Example: I was present during the entirety (insertion through removal) of the _________________.
Surgical Procedures
Surgery – Single
When a teaching physician is present for the ENTIRETY of a single surgical procedure, his/her presence may be demonstrated by documentation in the record by the resident, OR nurse, or the physician. Nothing more is required of the teaching physician in this scenario with regards to the teaching physician rules. If the documentation doesn’t specifically say they were present for the entirety, then the teaching physician must document an attestation stating they were present for the critical/key portions of the surgical procedure.
Example: Dr. Smith was present during the entirety of colectomy procedure (documented by resident).
Surgery – Two Overlapping
Must be present for the critical/key portions of each overlapping surgery. Surgeon decides which portions constitute critical/key. Medicare does not pay for more than two overlapping procedures. Please see Transmittal 811 for additional requirements for being immediately available during other portions of the surgeries.
Example: I was present for the critical/key portion of ____________________ (documented on BOTH operative reports). Documentation Tip: Documenting what the specific critical/key portion was, solidifies your presence, but is not required.
Surgery – Minor Procedures
Must personally perform, or be present for the entirety of the minor procedure.
Example: I was present for the entirety of the lumbar puncture.
Surgery – Assistant Surgeon
Assistant at surgery is not allowed in an academic setting where qualified residents are available. If a qualified resident is not available, you will need to append an attestation statement stating so, and why, and append an -82 modifier on the surgical assistant’s claim.
If you have questions regarding Teaching Physician requirements, please reach out to your compliance liaison. You may also reach out to Jay.McVean@uth.tmc or Caroline.Wolbrecht@uth.tmc.edu.
CMS/Novitas Resources:
Transmittal 2303 Teaching Physicians