Teaching Physician Rules – The Basics
The pandemic changed everything in the interim. Recently, CMS declared the pandemic was over, May 11, 2023. However, some of the waivers still remain. As we transition back to the requirements we knew prior to, let’s do a quick refresh on the basics.
Medicare Coverage
Medicare pays for services in a teaching setting using the Medicare Physician Fee Schedule (PFS) when the services meet 1 of these criteria:
● Physicians, not residents, personally provide the service (42 CFR 415.170)
● Residents provide the service when teaching physicians are physically present during critical or key service parts (42 CFR 415.172)
● This includes telehealth services through audio/video real-time technology in residency training sites outside a Metropolitan Statistical Area (MSA)
● Teaching physicians providing Evaluation and Management (E/M) services with a Graduate Medical Education (GME) program granted a primary care exception may bill Medicare for lower and mid-level E/M services provided by residents (42 CFR 415.174)
Supervision Requirements
In order for a service performed by a resident to be considered billable, the Teaching Physician must have provided direct supervision. During the pandemic, supervision was allowed via audio/visual modalities. That PHE waiver ends, December 31, 2023.
Billing Requirements
Documentation must support the service reported. Additionally, it must also demonstrate the appropriate supervision requirements were met (TPA – Teaching Physician Attestation) for the type of service performed. Additionally, CMS requires a modifier that certifies these requirements were met.
-GC: This service has been performed in part by a resident under the direction of a teaching physician
-GE: This service has been performed by a resident without the presence of a teaching physician under the primary care exception
Documentation Requirements
Teaching physicians billing E/M services must personally document:
- Personal presence (critical/key portion)
- Personal involvement in patient management
After providing the service, you must document the medical record with the teaching physician’s physical or virtual presence (if present through audio/video real-time technology), including telehealth services, only in residency training sites outside an MSA. Medical records must note the specific service part done during the physician’s presence, through audio/video real-time technology.
Primary Care Exception (PCE)
The only exception to this, is when the E/M service is provided in a PCE (Primary Care Exception) area. Independent resident services provided in the PCE up to a level three (3) may be billed by the supervising teaching physician when they review the service. Their presence is not required. The service does need to be reviewed immediately or shortly after the service was performed.
Below, are the CPT/HCPCS codes that are allowed in the PCE. The supervising teaching physician can report services other than these, however, the regular teaching physician requirements apply.
Residency programs most likely to qualify for the primary care exception include Family Practice, IM/General Medicine, IM/Geriatric medicine, Pediatrics, Obstetrics, and or Gynecology.
We are working on additional articles that dive into different types of service requirements, possible TPA statements, and other areas involved in the Teaching Physician arena.
If you have questions regarding Teaching Physician requirements, please reach out to your compliance liaison. You may also reach out to [email protected] or [email protected].
CMS/Novitas Resources:
Transmittal 11842 2023 E/M Changes
Transmittal 2303 Teaching Physicians