ED Coding and Reimbursement Alert

Learn to bill correctly when doctors - and med students - work together

If you want to get your emergency department physicians paid for evaluation and management (E/M) services and minor surgical procedures they perform in a teaching setting, you have to know these documentation and supervision requirements for the teaching physician rules, especially if you work in an academic setting.
 
When your physician works as a "teaching physician" (TP) and supervises a resident's services, you will have to report your physician's work using the teaching physician rules, according to the Medicare Carriers Manual (MCM), section 15016. Medicare recently released Transmittal 1780 to clarify some of the language in this section.
 
To appropriately report services under the teaching physician rules, make sure your resident meets Medicare's definition. The MCM defines residents as an intern or fellow who's enrolled in an accredited graduate medical education (GME) program, says Marti Geron, CPC, CMA, CM, coding and reimbursement manager at the University of Texas Southwestern Medical Center at Dallas. Experts offer four field-tested strategies for reporting E/M services and minor surgical procedures using the teaching physician rules.

1. Report E/M Services Based on 'Key Portions'

You can report E/M codes if the TP personally furnishes the E/M service, such as an ED visit (99281-99285), without the resident present, said Jillian H. Kuruc, MHA, CPC, CCS-P, a clinical technical editor with Ingenix Health Intelligence in Binghamton, N.Y., during a session on the teaching physician rules at the Third Annual Coding, Billing, and Compliance Essentials Conference in Orlando, Fla.
 
If the resident also performed this E/M service, your ED doctor would have to duplicate or be physically present during the "critical and key portions" of the resident's services to bill under this guideline, Kuruc tells ED Coding Alert. The TP should define - and be able to defend - those critical and key portions, she adds.
 
If you had an acute exacerbation of asthma, the TP would need to be present for the key or critical components of the E/M service, but he doesn't need to be there for the nebulizer treatments.
 
The TP doesn't have to duplicate the resident's progress notes but should refer to the resident's notes and state that the TP reviewed the resident's medical documentation and agrees with the diagnosis, Geron says.
 
If the TP was not present for the resident's evaluation of the patient, and the resident did not document a complete E/M service, your physician must bill and document the visit as he would in a non-teaching setting, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. In other words, to support a 99284 claim, the doctor would have to document a detailed history, a detailed examination, and moderate- complexity medical decision-making.

2. Document Physician Presence for Critical Care

The ED physician can also perform an E/M service jointly with the resident, Kuruc says. Suppose a patient presents with a fever (780.6), respiratory distress (786.09), and low blood pressure (458.x). The TP treats the patient with antibiotics and intravenous fluids, and the resident evaluates the patient's condition. Later, the TP admits the patient to the critical care unit for septic shock (785.52). Overall, the physician and the resident treated the patient for 35 minutes.
 
In this case, your physician may be able to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient ...), as long as the documentation supports the code.
 
The TP should document that the critical care time doesn't include the injection and that he treated the patient jointly with the resident. Also, the TP should note that he directly supervised the resident for the full 35 minutes of treatment and directly managed the patient's care, and reference the resident's note, Pohlig says. You should not include any time spent teaching that is not directly related to the critical care of the patient in your time.

3. Supervision Is Key to Reporting Minor Surgeries

When you report minor surgeries and endoscopic procedures, you should make sure the physician doc-uments that he directly supervised the entire procedure, Kuruc says. That means Medicare requires the physician's presence in the room. For example, your physician can't view the endoscopy procedure through a monitor in another room, Pohlig says.
 
If, for example, the minor procedure (defined as fewer  than 5 minutes) is a simple laceration repair, TPs must be physically present for the entire repair - they cannot just inspect the closure after the resident completes it.